Fillable Hemophilia Pharmacy Prior Authorization Request Form (Mercy Care)

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Hemophilia Pharmacy Prior Authorization Request Form (Mercy Care)

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The Hemophilia Pharmacy Prior Authorization Request Form (Mercy Care) form is 3 pages long and contains:

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

Country of origin: US
File type: PDF

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Page 1 of 3
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
Hemophilia
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 are required to support diagnosis
Member Information
Member Name (first & last):
Date of Birth:
Gender:
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
Request is for (specify medication name):
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
What medication(s) has member tried and failed for this diagnosis? Please specify below.
Directions for Use:
Strength:
Dosage Form:
Quantity:
Day Supply:
Duration of Therapy/Use:
Turn-Around Time for Review
Standard – (24 hours)
Urgent – If 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 Hemophilia A or B OR Von Willebrand disease with current serious OR life-threatening bleeds?
Yes
No
Hemophilia A (Inherited Factor VIII Deficiency)
Is there <1% of normal Factor VIII (less than 0.01 IU/mL)?
Yes
No
Does member have history of one or more episodes of spontaneous bleeding into joints (for example, routine
bleeding prophylaxis, hemorrhage, perioperative bleeding)?
Yes
No
Renewal ONLY:
Was member screened for inhibitors since last approval?
Yes
No
Is an inhibitor present?
Yes
No
If an inhibitor is present, is there a treatment plan to
address inhibitors as appropriate?
Yes
No
N/A
☐ Hemophilia B (Inherited Factor IX Deficiency)
Is there < 1% of normal Factor IX (less than 0.01 IU/mL)?
Yes
No
Does member have history of one or more episodes of spontaneous bleeding into joints (for example, routine
bleeding prophylaxis, hemorrhage, perioperative bleeding)?
Yes
No
Renewal ONLY:
Was member screened for inhibitors since last approval?
Yes
No
Is an inhibitor present?
Yes
No
If an inhibitor is present, is there a treatment plan to
Yes
No
N/A
Effective: 08/18/2020 C6417-A, C6418-A, C6419-A, C6420-A, C13272-A, C13274-A, C13383-A, C13384-A
Proprietary
click to sign
signature
click to edit
☐
address inhibitors as appropriate?
Von Willebrand Disease
Does member have a laboratory confirmed diagnosis?
Yes
No
Does member have history of bleed (for example, prolonged wound bleed, post-surgical or dental bleed, nosebleeds,
menorrhagia, excessive bruising, or family history of bleeding or bleeding disorder)?
Yes
No
Novo-Seven RT (Recombinant Activated Factor VII Concentrate (Factor VIIa))
Member has ONE of the following FDA
approved indications (check one):
Acquired hemophilia
Congenital Factor VII deficiency
Hemophilia A or B with Inhibitors
Glanzmann’s thrombasthenia, when refractory to
platelet transfusions, with or without antibodies to
platelets
Is treatment for hemorrhagic complications OR prevention of bleeds in surgical OR invasive procedures?
Yes
No
Renewal ONLY:
Is an inhibitor present?
Yes
No
If an inhibitor is present, is there a treatment plan to
address inhibitors as appropriate?
Yes
No
N/A
Feiba (Activated Prothrombin Complex Concentrate)
Will Feiba be used for Hemophilia A or Hemophilia B with inhibitors?
Yes
No
Will Feiba be used for the treatment of hemorrhagic complications, or prevention of bleeds, in surgical, or invasive
procedures, or routine prophylaxis?
Yes
No
Renewal ONLY:
Is an inhibitor present?
Yes
No
If an inhibitor is present, is there a treatment plan to
address inhibitors as appropriate?
Yes
No
N/A
Obizur
Will Obizur be used for acquired Hemophilia A in
adults (for treatment of bleeding episodes)?
Yes
No
Is baseline anti-porcine Factor VIII
inhibitor titer NOT > 20 Bethesda Units?
Yes
No
Renewal ONLY:
Is inhibitor present?
Yes
No
If inhibitor is present, is there a treatment plan to
address inhibitors as appropriate?
Yes
No
N/A
Hemlibra
Will Hemlibra be used for prophylaxis of Hemophilia A with or without inhibitors?
Yes
No
Is there severe disease with documentation showing <1% of normal Factor VIII (<0.01 IU/mL)?
Yes
No
Is disease mild or moderate with
documentation showing ≥1% of normal
Factor VIII (≥0.01 IU/mL)?
Yes
No
Is there documentation showing at least
TWO episodes of bleeding into the joints?
Yes
No
Members without inhibitors have tried and failed
OR have documented contraindications to TWO
prophylactic factor VIII replacement products?
Yes
No
N/A
Will medication be used for
treatment of acute bleeds?
Yes
No
Provider confirms that member will D/C any
use of factor VIII products as prophylactic
therapy while on Hemlibra (on-demand
usage may be continued)?
Yes
No
Cumulative amount of >100 U/kg/24hrs of
activated prothrombin complex concentrate
has not been GIVEN for 24 HRS or more.
(examples of activated prothrombin complex
concentrate include Feiba, Novoseven RT)?
Yes
No
Renewal ONLY:
Is inhibitor present?
Yes
No
If inhibitor is present, is there a treatment plan to
address inhibitors as appropriate?
Yes
No
N/A
Additional information the prescribing provider feels is important to this review. Please specify below OR submit medical records.
Effective: 08/18/2020 C6417-A, C6418-A, C6419-A, C6420-A, C13272-A, C13274-A, C13383-A, C13384-A Page 2 of 3
Proprietary
____________________________________________________ __________________
Signature affirms that information given on this form is true and accurate and reflects office notes.
Prescribing Provider’s Signature: Date:
Please note: Incomplete for
ms 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: 08/18/2020 C6417-A, C6418-A, C6419-A, C6420-A, C13272-A, C13274-A, C13383-A, C13384-A
Proprietary
Page 3 of 3
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Hemophilia Pharmacy Prior Authorization Request Form (Mercy Care)

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Completed 31 July 2021

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