_____________________________________________________
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
Epidiolex
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): 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 ONLY:
Has member had a
decrease in seizure
frequency from baseline?
Yes No Was serum transaminase level NOT
>3 times ULN while accompanied by
bilirubin > 2 times ULN?
Yes No
Was serum transaminase level NOT sustained at >5 times ULN? Yes No
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
Will Epidiolex be taken as adjunctive therapy to
ONE other antiepileptic drug?
Yes No Is prescribed dose appropriate for
member’s liver function AND does not
exceed 20mg/kg/day?
Yes No
Were serum transaminases AND total bilirubin levels obtained prior to start AND will be taken periodically as
appropriate (per FDA approved labeling)?
Yes No
Lennox-Gastaut Syndrome
Has member tried AND failed OR
has intolerance OR contraindication
to Onfi (clobazam)?
Yes No Member had trial AND failure OR
intolerance OR contraindication with
TWO of the following:
valproic acid topiramate
felbamate lamotrigine
Dravet Syndrome
Was there trial AND failure OR intolerance OR
contraindication to Onfi (clobazam)?
Yes No Member had trial AND
failure OR intolerance OR
contraindication with ONE
of the following?
levetiracetam topiramate
zonisamide lamotrigine
felbamate
Additional information prescribing provider feels is important to this review. Please specify below or submit medical records.
Effective: 06/08/2020 C15498-A 02-2020 Page 1 of 2
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