Fillable Dupixent Pharmacy Prior Authorization Request Form (Mercy Care)

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Dupixent Pharmacy Prior Authorization Request Form (Mercy Care)

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

  • 2 signatures
  • 12 check-boxes
  • 99 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 ret urned
Pharmacy Coverage
Guidelines are available at
www.mercycareaz.org/providers/completecare-forproviders/pharmacy
Dupixent
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:
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:
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
Moderate to Severe Atopic Dermatitis
Were lab results using Patient-Oriented
Eczema Measure (POEM) score at ≥ 8?
Yes
No
Were lab results of Investigator’s Global
Assessment (IGA) score at ≥ 3?
Yes
No
Was there inadequate response OR intolerable
side effect with TWO preferred - medium to
very high potency - topical corticosteroids?
Yes
No
Was there inadequate response OR
intolerable side effect with ONE preferred
low potency topical corticosteroid, for
sensitive areas, such as face?
Yes
No
Was there inadequate response OR intolerable
side effect to tacrolimus?
Yes
No
Was there inadequate response or
intolerable side effect to ONE oral systemic
therapy such as methotrexate OR
cyclosporine OR azathioprine OR
mycophenolate?
Yes
No
Renewal Requests ONLY
Did member have a response to therapy, for
example, reduction in lesions?
Yes
No
Was the score for Patient-Oriented Eczema
Measure (POEM) 0 to 2 (clear or almost
clear)?
Yes
No
Was the Investigator’s Global Assessment (IGA) score 0 or 1 (clear or almost clear)?
Yes
No
Moderate to Severe Asthma
Effective: 04/01/2020 C11360-A 12/2019
Proprietary
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Page 2 of 2
Was
the e
osinophilic phenotype, with
pretreatment eosinophil count ≥150/microL?
Yes
No
Does member have corticosteroid
dependent asthma (≥5 mg of oral
prednisone or equivalent per day)?
Yes
No
Will Dupixent be used as ADD ON therapy to a
medium or high dose ICS plus ONE additional
controller such as LABA OR LAMA?
Yes
No
Was there compliance with the medium to
high dose ICS plus ONE LABA OR LAMA
OR another controller for at least THREE
months AND member remained
symptomatic?
Yes
No
Is there daily use of rescue medications such
as SABA?
Yes
No
Are nighttime symptoms occurring one OR
more times per week?
Yes
No
Were there a minimum of TWO exacerbations
in the last 12 months requiring additional
medical treatment (For example, systemic
corticosteroids, ER visits, or hospitalization)?
Yes
No
Is the FEV1< 80% predicted?
Yes
No
Will Dupixent be used with another monoclonal antibody?
Yes
No
Renewal Request ONLY
Was there a response to therapy such as decrease in exacerbations OR decrease in dose of oral steroids OR
improvement in FEV1 from baseline)?
Yes
No
Will Dupixent continued to be used as add on
therapy to another asthma medication?
Yes
No
Will Dupixent be used with another
monoclonal antibody?
Yes
No
Chronic Rhinosinusitis with Nasal Polyposis
Will Dupixent be used as add-on therapy to intranasal corticosteroids?
Yes
No
Have symptoms persisted for at least 12 weeks and TWO out of
FOUR hallmark signs AND symptoms a re present? (if yes, check that
apply):
Yes No
Mucopurulent drainage
Nasal obstruction
Decreased sense o
f smell
Facial pain, pressure, and/or fullness
Has prescriber confirmed mucosal
inflammation is present?
Yes
No
Was condition inadequately controlled by systemic
corticosteroids AND/OR sinus surgery following
intranasal corticosteroids?
Yes
No
Renewal Request ONLY
Was there response to therapy?
Yes
No
Was there decrease in bilateral endoscopic
nasal polyps score from baseline?
Yes
No
Was there a decrease in the nasal congestion /
obstruction score from baseline?
Yes
No
Will Dupixent continue to be used as add
on therapy to intranasal corticosteroids?
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: 04/01/2020 C11360-A 12/2019
Proprietary
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click to edit
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Dupixent Pharmacy Prior Authorization Request Form (Mercy Care)

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Completed 31 July 2021

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