Effective: 03/01/2021 C4491-A 12-2019 Page 1 of 2
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
Hyaluronic Acid Derivatives
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:
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
Preferred Agents: Gel-One Visco-3
Medication request is NOT for an FDA approved, or
compendia supported diagnosis (circle one): Yes No
ICD-10 Code: Diagnosis:
What medication(s) have been tried and failed for diagnosis?
Are there any contraindications to formulary medications? Yes No
If
yes, please specify:
New
request
Continuation of
therapy request
Continuation of therapy
request ONLY:
Have SIX months
elapsed since
previous TX?
Yes No Is there documentation to support improved
response to previous series? (Dose reduction
with NSAIDs OR other analgesics)
Yes No
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
Was there inadequate response, intolerable side effect, or contraindication to non-pharmacologic therapy (for
example, physical therapy, land based or aquatic based exercise, resistance training, or weight loss)?
Yes No
Was there inadequate response, intolerable side effect, or contraindication to trial of pharmacologic therapy, one of
which must be oral or topical NSAIDs?
Yes No
Was there inadequate response, intolerable side effect, or contraindication to intra-articular steroid injections? Yes No
Does the pain interfere with functional activities (for example,
ambulation, or prolonged standing?
Yes No Is the pain attributed to other
forms of joint disease?
Yes No
Did member have surgery on the same knee in the past 6 months? Yes No
Treatment request is due to any of the following indications?
☐ Temporomandibular joint disorders
☐ Chondromalacia of patella (chondromalacia patellae)
☐ Pain in joint, lower leg (patellofemoral syndrome)
☐ Osteoarthrosis and allied disorders (joints other than knee)
☐ Diagnosis of osteoarthritis of hip, hand, shoulder, etc.
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