Fillable Janus Associated Kinase Inhibitors Pharmacy Prior Authorization Request (Mercy Care)

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Janus Associated Kinase Inhibitors Pharmacy Prior Authorization Request (Mercy Care)

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The Janus Associated Kinase Inhibitors Pharmacy Prior Authorization Request (Mercy Care) form is 2 pages long and contains:

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  • 21 check-boxes
  • 91 other fields

Country of origin: US
File type: PDF

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Effective: 04/01/2020 C6499-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 be provided. Incomplete forms or forms without the chart notes will be returned
Pharmacy Coverag
e Guideli
nes are available at www.mercycareaz.org/providers/completecare-forproviders/pharmacy
Janus Associated Kinase Inhibitors
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 Nam
e (first & last): Specialty: NPI#
DEA#
Office Address: City: State: Zip Code:
Office Contact: Office Phone Office Fax:
Dispensing Pharmacy Info
rmation
Pharmacy Name: Pharmacy Phone: Pharmacy Fax:
Requested Medication Information
Inrebic Jakaf
i Other, please specify:
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, pleas
e specify:
Initial
Request
Continuation
of Therapy
Directions for Use: Strength: Dosage Form:
Quantity: Day Supply:
Duration
of Therapy/Use:
Turn-Around Time for Review
Standard – (2
4 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 I
nformation
Has member been screened for
TB?
Yes No Was screeni
ng positive for latent TB? Yes No
Was treatment for latent TB receiv
ed
prior to initiating therapy?
Yes No N/A
Is there evidence showing that member ha
s a serious current ACTIVE infection? Yes No
Myelofibrosis
Is baseline PLT count at l
east 50 X 109/L? Yes No
Does member have TWO or more of the
following risk fac
tors?
Age >65 years Red Cell Tr
ansfusion
Constitutional symptoms (weight loss > 10% from bas
eline AND/OR unexplained fever
OR excessive sweats persisting > 1 month)
Hemoglobin <10g/dL WBC count ≥25
x 109/L
Peripheral Blood blasts >1% Platelet count <100 X 109/L
Unfavorable
karyotype [complex karyotype OR sole OR two abnorma
lities that include
trisomy 8, 7/7q-, i(17q), inv (3), 5/5q-, 12p- OR 11q23 rearrangement]
Additionally, for Inrebic
Is documentation showing signs of
severe hepatic
impairment (baseline
bilirubin >3-times ULN)?
Yes No Is documentation showing thiamine levels were
taken at baseline AND then periodically during
therapy to avoid Wernicke’s encephalopathy?
Yes No
Renewal Request ONLY
Was there spleen size re
duction ≥ 35%? Yes No Was there symptom improvement (≥50% reduction
in total symptom score from baseline)?
Yes No
Is there absence of disease progression? Yes No
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Page 2 of 2
___________________________________________________ __________________
Additionally, for Inrebic Renewal
Is documentation showing LFTs AND thiamine levels are being monitored periodically during therapy? Yes No
Polycythemia Vera
Is HgB >16.5 g/dL
in MEN OR >16.0 g/dL in
WOMEN?
Yes No Is HCT >49% in MEN OR >48% in
WOMEN?
Yes No
Is there increased red cell
mass?
Yes No Does a bone
marrow biopsy show hypercellularity for age with
trilineage growth (panmyelosis), including prominent erythroid,
granulocytic AND megakaryocytic proliferation with pleomorphic,
mature megakaryocytes (differences in size)?
Yes No
Is there presence of JAK2 V617F mutation OR
JAK2 exon 12 mutation?
Yes No Is there subnormal serum erythropoietin
level?
Yes No
Renewal Request ONLY
Was there hematologic improvement (decreased
HCT, P
LT count or WBC count)?
Yes No Was there a reduction in palpable spleen
length?
Yes No
Has there been improvement in symptoms (for example, pruritus, night sweats, bone pain)? Yes No
Acute Graft-Versus-Host
Disease
Was there inadequate response to steroids after
allogenic h
ematopoietic stem cell transplant?
Yes No Is there diagnosis of grade 2-4 disease,
based on Mount Sinai Acute GVHD
International Consortium criteria?
Yes No
Renewal Request ONLY
Was t
here response to treatment? Yes No Are sympt
oms recurring during OR after
taper AND retreatment is needed?
Yes No
Additional information the prescribing provider feels is important to this review. Please specify below or submit medical records
Signatu
re 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 C6499-A 12-2019
Proprietary
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Janus Associated Kinase Inhibitors Pharmacy Prior Authorization Request (Mercy Care)

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Completed 31 July 2021

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