Fillable Corlanor Pharmacy Prior Authorization Request Form (Mercy Care)

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Corlanor Pharmacy Prior Authorization Request Form (Mercy Care)

On average this form takes 20 minutes to complete

The Corlanor Pharmacy Prior Authorization Request Form (Mercy Care) form is 2 pages long and contains:

  • 2 signatures
  • 15 check-boxes
  • 63 other fields

Country of origin: US
File type: PDF

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Fax completed prior authorization request form to 800-854-7614 or submit Electronic Prior Authorization
through CoverMyMeds® or SureScripts.
All requested data must be provided. Incomplete forms or forms without the chart notes will be returned
Pharmacy Coverage Guidelines are available at
www.mercycareaz.org/providers/completecare-
forproviders/pharmacy
Corlanor
Pharmacy Prior Authorization Request Form
Do not copy for future use. Forms are updated frequently.
REQUIRED: Office notes, labs and medical testing relevant to request showing medical justification to support diagnosis
Member Information
Member Name (first & last):
Date of Birth:
Gender:
Male
Female
Height:
Member ID:
City:
State:
Weight:
Prescribing Provider Information
Provider Name (first & last):
NPI#
DEA#
Office Address:
State:
Zip Code:
Office Contact:
Office Phone
Office Fax:
Dispensing Pharmacy Information
Pharmacy Name:
Pharmacy Phone:
Pharmacy Fax:
Requested Medication Information
Medication request is NOT for an FDA- approved, or
compendia-supported diagnosis (circle one):
Yes No
Diagnosis:
ICD-10 Code:
Are there any contraindications to formulary medications?
Yes
No
If yes, please specify:
New
request
Continuation of
therapy request
Directions for Use:
Strength:
Dosage Form:
Quantity:
Day Supply:
Duration of Therapy/Use:
What medication(s) has the member tried and failed for this diagnosis? Please specify below.
Turn-Around Time for Review
Standard – (24 hours)
Urgent – waiting 24 hours for a standard decision could seriously harm life, health,
or ability to regain maximum function, you can ask for an expedited decision.
Signature: _____________________________________________________
Clinical Information
☐
Members 18 Years of Age or Older
Does member have diagnosis of stable
symptomatic chronic HF (NYHA Class II-III)?
Yes
No
Is LVEF ≤ 35%?
Yes
No
Is member in sinus rhythm with resting HR ≥70
BPM?
Yes
No
Is there continuation of therapy with
maximally tolerated BB OR there is
intolerance OR contraindication to BB?
Yes
No
Is there continuation of therapy with ACEI / ARB OR Entresto OR there is intolerance OR contraindication to ACEI /
ARB OR Entresto?
Yes
No
Provider attestation that no contraindications to
treatment exist? (check all that apply):
☐ Acute decompensated heart failure
☐
☐
Blood pressure less than 90/50 mmHg
Pacemaker dependent (for example: heart rate maintained exclusively by pacemaker)
☐ Sick sinus syndrome, sinoatrial block of third-degree AV block (unless functioning
demand pacemaker is present)
☐
☐
Severe hepatic impairment (Child-Pugh class C)
Pediatric Members 6 Months of Age or Older
Does member have diagnosis of HF due to
dilated cardiomyopathy?
Yes
No
Is member in sinus rhythm with resting HR
of ≥70 BPM?
Yes
No
Provider attestation that no contraindications to
treatment exist (check all that apply):
Yes
No
☐ Acute decompensated heart failure
☐ Blood pressure less than 90/50 mmHg
Effective: 06/08/2020 C10860-C 03-2020 Page 1 of 2
Proprietary
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signature
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Page 2 of 2
☐ Pacemaker dependent (for example: heart rate maintained
exclusively by pacemaker)
Sick sinus syndrome, sinoatrial block of third-degree AV bloc
k
(unless functioning demand pacemaker is present)
Severe hepatic impairment
(Child-P
ugh class C)
☐
☐
Does member have intolerance OR contraindication to trimethoprim-sulfamethoxazole?
(for non-life-threatening reactions, the national AIDS guideline recommends re-challenge)
Yes
No
Renewal ONLY
Is member responding
to treatment?
Yes
No
Is HR within recommended range for continuation of maintenance
dose (for example, 50-60 BPM or dose adjusted accordingly to
achieve goals member seropositive for anti-toxoplasma IgG)?
Yes
No
Additional information the prescribing provider feels is important to this review. Please specify below or submit medical records.
Signature affirms that information given on this form is true and accurate and reflects office notes.
Prescribing Provider’s Signature: ___________________________________________________ Date: __________________
Please note: Incomplete forms or forms without the chart notes will be returned
Office notes, labs, and medical testing relevant to the request that show medical justification are required.
Standard turnaround time is 24 hours. You can call 800-624-3879 to check the status of a request.
Effective: 06/08/2020 C10860-C 03-2020
Proprietary
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Corlanor Pharmacy Prior Authorization Request Form (Mercy Care)

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Completed 31 July 2021

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