Fillable Pharmacy Prior Authorization Request Form Botulinum Toxins (Mercy Care)

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Pharmacy Prior Authorization Request Form Botulinum Toxins (Mercy Care)

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

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  • 43 check-boxes
  • 83 other fields

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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
Botulinum Toxins
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 justifi
cation 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
Botox
Dysport
Myobloc
Xeomin
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, please specify:
Directions for Use:
Strength:
Dosage Form:
Quantity:
Day Supply:
Duration of Therapy/Use:
Turn-Around Time for Review
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
Migraine Prophylaxis
Botox
Will Botox be used for prevention of chronic migraine (at least 15
days per month with headaches lasting 4 hours a day or longer)?
Yes
No
Will requested medication be used
concurrently with CGRP antagonist?
Yes
No
There was inadequate response OR intolerable side effects to at least
THREE medications from TWO different classes of migraine
headache prophylaxis for at least THREE months (check that apply):
Beta-Blockers: propranolol, metoprolol, timolol, atenolol, nadolol
Anticonvulsant: valproic acid or divalproex, topiramate
Antidepressa
nts: amitriptyline, venlafaxine
ACE-Is / ARBs: lisinopril, candesartan, losartan, valsartan
Calcium Channel Blockers: diltiazem, nifedipine, nimodipine, verapamil
Renewal Request ONLY
Was migraine headache frequency reduced by at
least 7 days per month by end of initial trial?
Yes
No
Was migraine headache duration reduced by at
least 100 hours per month by end of initial trial?
Yes
No
Chronic Limb Spasticity
Botox
Xeomin
Dysport
Is spasticity due to an injury to the brain or spinal cord, or along with a neurological disorder (for example, stroke, traumatic
brain injury, multiple sclerosis, spinal cord injury, cerebral palsy)?
Yes
No
Effective: 04/01/2020 C4395-A 12-2019
Proprietary
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signature
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Page 2 of 3
Effective: 04/01/2020 C4395-A 12-2019
Proprietary
Does member have upper limb spasticity?
Yes
No
Does member have lower limb spasticity?
Yes
No
Was there failure with baclofen AND at least ONE
other formulary muscle relaxant such as dantrolene?
Yes
No
Was there a trial of physical and/or
occupational therapy?
Yes
No
Severe Primary Axillary Hyperhidrosis
Botox
Dysport
There was focal, visible, excessive sweating for at least SIX months without
apparent cause with TWO of the following (check that apply):
Interferes with daily activities
Bilateral and relatively symmetric
Onset before 25 years of age
Focal sweating stops during sleep
Family history of idiopathic hyperhidrosis
At least one episode per week
Was there failure with topical aluminum chloride (hexahydrate)?
Yes
No
Neurogenic Bladder
Botox
Is diagnosis of urinary incontinence due to detrusor overactivity associated with neurologic condition?
Yes
No
Was there trial of behavioral therapy (for example, bladder training, bladder control strategies, pelvic floor muscle training,
fluid management) for at least 8-12 weeks?
Yes
No
Was there a trial and failure with TWO formulary urinary anticholinergics (for example, oxybutynin, trospium, tolterodine)?
Yes
No
Overactive Bladder
Botox
Was a trial of behavioral therapy (for example, bladder training, bladder control strategies, pelvic floor muscle training, fluid
management) for at least 8-12 weeks?
Yes
No
Was there trial and failure with TWO formulary urinary anticholinergics (for example, oxybutynin, trospium, tolterodine)?
Yes
No
Esophageal Achalasia
Botox
Has member remained symptomatic despite
surgical myotomy or pneumatic dilation?
Yes
No
Is member at high surgical risk or is unwilling to
undergo surgical myotomy or pneumatic dilation?
Yes
No
Chronic Anal Fissures
Botox
Was there a trial and failure with nitroglycerin ointment
0.4% (Rectiv) AND bulk fiber supplements OR stool
softeners OR sitz baths for at least TWO months?
Yes
No
Was endoscopy completed to rule out
Crohn’s disease?
Yes
No
Chronic Sialorrhea
Botox
Myobloc
Xeomin
Was there trial and failure with anticholinergic such as glycopyrrolate (pediatric use 3-16) or benztropine (adults)?
Yes
No
Focal Spasticity or Equinus Gait due to Cerebral Palsy
Botox
Dysport
Is member enrolled in OR is currently being managed with physical and/or occupational therapy?
Yes
No
Additional information the prescribing provider feels is important to this review. Please specify below or submit medical records
Page 3 of 3
__________________ ___________________________________________________
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 chec
k the status of a request.
Effective
: 04/01/2020 C4395-A 12-2019
Proprietary
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Pharmacy Prior Authorization Request Form Botulinum Toxins (Mercy Care)

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Completed 31 July 2021

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