Fillable Monoamine Depletors Pharmacy Prior Authorization Request Form (Mercy Care)

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Monoamine Depletors Pharmacy Prior Authorization Request Form (Mercy Care)

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

  • 2 signatures
  • 26 check-boxes
  • 60 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 returned
Pharmacy Coverage Guidelines are available at www.mercycareaz.org/providers/completecare-forproviders/pharmacy
Monoamine Depletors
Pharmacy Prior Authorization Request Form
Do not copy for future use. Forms are updated frequently
REQUIRED: Medical records, including labs and weight or body surface area (BSA), to support diagnosis are required to be submitted
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
Austedo
Tetrabenazine
Ingrezza
Are there any hypersensitivity OR contraindications to formulary medications? (circle one):
Yes No
New request
Continuation of
therapy ONLY:
Chemotherapy-
induced neutropenia:
Recent ANC showing
response to therapy
All other
indications:
Recent ANC, CBC or PLT
counts
Directions for Use:
Strength:
Dosage Form:
Quantity:
Day Supply:
Duration of Therapy/Use:
Medication request is NOT for an FDA approved, or compendia-
supported diagnosis (circle one):
Yes No
ICD-10 Code:
Diagnosis:
What medications(s) has member tried and failed for this diagnosis? Please specify below.
Turn-Around Time
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
Is member receiving concurrent therapy with MAOI (selegiline, reserpine) OR additional VMAT2 inhibitor
(tetrabenazine, valbenazine)?
Yes
No
Member has
the following:
Active suicidal
thoughts or behavior
Hepatic
dysfunction
Untreated OR
undertreated
depression
Congenital long QT syndrome,
OR arrhythmias associated
with prolonged QT interval
None
apply
Tardive Dyskinesia – INITIAL REQUEST
Is diagnosis moderate to severe tardive
dyskinesia?
Yes
No
Is AIMS score ≥6?
Yes
No
Has provider attempted alternative method to manage condition (dose reduction, discontinuation of offending
medication OR switching to alterative agent such as atypical antipsychotic)?
Yes
No
Please specify which atypical antipsychotic was used:
Please specify time frame of stability on atypical antipsychotic:
Tardive Dyskinesia – RENEWAL REQUEST
Was there improvement in AIMS score (decrease from baseline by at least TWO points)?
Yes
No
Provider is monitoring for
Suicidal thoughts
EKG, for members at
Hepatic dysfunction
Emergent or
Effective: 06/08/2020 C10858-A 02-2020 Page 1 of 2
Proprietary
click to sign
signature
click to edit
Page 2 of 2
ALL the following:
and behaviors
risk for QT prolongation
(for Austedo only)
worsening depression
Huntington’s Chorea – INITIAL REQUEST
Is diagnosis confirmed by neurologist
consult AND genetic testing?
Yes
No
Was there inadequate response OR
intolerable side effects to amantadine?
Yes
No
Does member have Unified Huntington's Disease Rating Scale (UHDRS) total maximal chorea score of ≥8?
Yes
No
Huntington’s Chorea – RENEWAL REQUEST
Did member have improvement in Total Maximal Chorea score ≥3 points from baseline?
Yes
No
Provider is monitoring for
ALL the following:
Suicidal thoughts
and behaviors
EKG, for members at
risk for QT prolongation
Hepatic dysfunction
(for Austedo only)
Emergent or
worsening depression
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.
Effec
tive: 06/08/2020 C10858-A 02-2020
Proprietary
click to sign
signature
click to edit
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Monoamine Depletors Pharmacy Prior Authorization Request Form (Mercy Care)

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Completed 31 July 2021

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