Fillable Pharmacy Prior Authorization Request Form (Mercy Care)

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Pharmacy Prior Authorization Request Form (Mercy Care)

On average this form takes 20 minutes to complete

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

  • 2 signatures
  • 14 check-boxes
  • 65 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
Pharmacy Prior Authorization Request Form
Do not copy for future use. Forms are updated frequently.
REQUIRED: Office notes, labs, and medical testing relevant to the request that show medical justification are required.
Member Information
Member Name (first & last):
Date of Birth:
Gender: M F 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 Name:
Strength:
Dosage Form:
Directions for Use:
Refills:
Duration of Therapy/Use:
Check if requesting brand only (Must include copy of MedWatch form)
Turn-Around Time For Review
Standard - (24 hours)
Urgent - by waiting 24 hours for a standard decision could seriously harm life, health, or ability to regain
maximum function, you can ask for an expedited (fast) decision. Signature:_______________________
Clinical Information
1. What is the diagnosis? Please specify below.
Medication request is NOT for an FDA-approved, or compendia-supported diagnosis
ICD-10 Code:
Diagnosis Description:
2.
New request
Continuation of therapy request
If yes, Please specify (circle one) how this medication was started:
Previous Prior Authorization, Paid under Another Insurance, Recent Hospital Discharge or Other
3.
Are there any contraindications to formulary medications?
Yes
If yes, please specify:
No
Is this a request for an increase or decrease in dose or
quantity of a previously approved medication?
Yes
No
_________________________________
4. What medication(s) has the individual tried and failed for this diagnosis? Please specify below.
Important note: Samples provided by the prescriber are not accepted as continuation of therapy or as an adequate trial and failure. For Brand name requests,
generic formulation from 2 different manufacturers is required along with MedWatch form.
Medication Name, Strength, Frequency
Dates started and stopped
or Approximate Dura
tion
Reason therapy was discontinued
5. Are there any supporting labs or test results? Please specify below.
Date Test Value
_____________________________
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Pharmacy Prior Authorization Request Form
6. Is there any additional information the prescribing provider feels is important to this review? Please specify below or submit
medical records.
For example, explain the negative impact on medical condition, safety issue, reason formulary agent is not suitable to a specific medical
condition, expected adverse clinical outcome from use of formulary agent, or reason different dosage form or dose is needed.
7.
Is request for a patient that is on an insulin pump?
Yes
No
Make and Model: __________________________________ _
Note: One Touch products are formulary.
Signature affirms that information given on this form is true and accurate and reflects office notes
Prescribing Provider’s Signature: Date:
Please note:
Some medications may require completion of a drug-specific request form. Please refer to plan website
at www.mercycareaz.org/providers/completecare-forproviders/pharmacy for drug-specific criteria forms.
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.
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Pharmacy Prior Authorization Request Form (Mercy Care)

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Completed 31 July 2021

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