Fillable Dalfampridine Pharmacy Prior Authorization Request Form (Mercy Care)

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Dalfampridine Pharmacy Prior Authorization Request Form (Mercy Care)

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

  • 2 signatures
  • 3 check-boxes
  • 61 other fields

Country of origin: US
File type: PDF

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Effective: 04/01/2020 C4391-A 12-2019 Page 1 of 2
Proprietary
Fax completed prior authorization request form to 800-854-7614 or submit Electronic Prior Authorization through
CoverMyMeds® or SureScripts.
All requested data must b
e 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
Dalfampridine
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
Height:
Member ID:
City:
State:
Weight:
Prescribing Provider Information
Provider Name (first & last):
Specialty:
NPI#
DEA#
Office Address:
City:
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
Does member have an impaired walking ability
defined as baseline 25-foot walking test
between 8 AND 45 seconds?
Yes
No
Does member have an expanded Disability
Status Scale between 4.5 AND 6.5?
Yes
No
Is member wheelchair bound?
Yes
No
Does member have history of seizures?
Yes
No
Has there been disease exacerbation in
previous 60 days?
Yes
No
Does member have moderate to severe
renal impairment (CrCl < 50 mL/min)?
Yes
No
Renewal Request ONLY
Was there improvement in timed walking speed
on 25-foot walk?
Yes
No
Was there stability or improvement in
Expanded Disability Status Scale score?
Yes
No
Does member have moderate to severe renal
impairment CrCl <50 mL/min)?
Yes
No
Was an annual Electroencephalography
test completed?
Yes
No
Additional information the prescribing provider feels is important to this review. Please specify below or submit medical records.
click to sign
signature
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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.
Standar
d turnaround time is 24 hours. You can call 800-624-3879 to check the status of a request.
Effective: 04/01/2020 C4391-A 12-2019
Proprietary
Page 2 of 2
________________________________
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Dalfampridine Pharmacy Prior Authorization Request Form (Mercy Care)

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Completed 31 July 2021

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