Fillable Pharmacy Prior Authorization Request Form Calcitonin Gene-Related Peptide (Mercy Care)

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Pharmacy Prior Authorization Request Form Calcitonin Gene-Related Peptide (Mercy Care)

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The Pharmacy Prior Authorization Request Form Calcitonin Gene-Related Peptide (Mercy Care) form is 2 pages long and contains:

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  • 39 check-boxes
  • 89 other fields

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File type: PDF

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Effective: 12/03/2020 C16835-C 09-2020
Proprietary
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 form
s or forms without the chart notes will be returned
Pharmacy Coverage Guidelines are available at www.mercycareaz.org/providers/completecare-forproviders/pharmacy
Calcitonin Gene-Related Peptide Receptor (CGRP) Antagonists
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
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:
Ajovy
Emgality
Non-Preferred Agents:
Aimovig
Nurtec ODT
Ubrelvy
Vyepti
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? (please specify):
Are there any contraindications to formulary medications?
Yes
No
(if yes, please specify)
Initial Request
Continuation of
Therapy Request
RENEWAL Requests ONLY:
PREVENTATIVE treatment
ACUTE treatment
Is there documentation of reduction in
migraine headache days from baseline?
Yes
No
Is there documentation of improvement
shown through provider clinical assessment?
Yes
No
Will medication be used in COMBO with another CGRP antagonist OR with Botox?
Yes
No
Aimovig 140mg ONLY:
Was there trial and failure with Aimovig 70mg?
Yes
No
Vyepti 300mg ONLY:
Was there trial and failure with Vyepti 100mg?
Yes
No
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
Directions for Use:
Strength:
Dosage Form:
Quantity:
Day Supply:
Duration of Therapy/Use:
Was there documented trial and failure OR
contraindication to Ajovy AND Emgality?
Yes
No
Will medication requested be used in COMBO
with another CGRP antagonist OR Botox?
Yes
No
Aimovig 140mg ONLY:
Did member have trial and failure with Aimovig 70mg?
Yes
No
Vyepti 300mg ONLY:
Did member have trial and failure with Vyepti 300mg?
Yes
No
Chronic Migraine
Aimovig
Emgality
Ajovy
Vyepti
Are headaches occurring on 15 OR MORE days per month with at least 8 migraine days per month for > 3 months?
Yes
No
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2 of 2
There is documented inadequate response OR intolerable side
effect to at least 2 medications for migraine prophylaxis from 2
different classes, for at least 2 months (check that apply):
Beta Blockers: Propranolol, metoprolol, atenolol, timolol, nadolol
Anticonvulsants: Valproic acid, divalproex, topiramate
Antidepressants: Amitriptyline, nortriptyline, venlafaxine, duloxetine
Episodic Migraine
Aimovig
Emgality
Ajovy
Vyepti
Does member have headaches occurring LESS THAN 15 days per month, with 4 to 14 migraine days per month?
Yes
No
There is documented inadequate response OR intolerable side
effect to at least 2 medications for migraine prophylaxis from 2
different classes, for at least 2 months (check that apply):
Beta Blockers: Propranolol, metoprolol, atenolol, timolol, nadolol
Anticonvulsants: Valproic acid, divalproex, topiramate
Antidepressants: Amitriptyline, nortriptyline, venlafaxine, duloxetine
Acute Migraines
Ubrelvy
Nurtec ODT
Will requested medication be used for moderate or
severe pain intensity?
Yes
No
Is CrCl < 15mL/min?
Yes
No
Is there documented inadequate response OR
intolerable side effects with at least 2 triptans?
Yes
No
Is there contraindication to triptan use?
Yes
No
Ubrelvy ONLY:
Does member experience MORE THAN 8 migraine
days per month?
Yes
No
Is there End Stage Renal Disease
(CrCl < 15 mL/min)?
Yes
No
Nurtec ODT ONLY:
Does member experience MORE THAN 15 migraine
days per month?
Yes
No
Is there severe hepatic impairment
(Child-Pugh class C)?
Yes
No
Does member have End Stage Renal Disease (CrCl <15 mL/min OR is on hemodialysis?
Yes
No
Episodic Cluster Headache
Emgality
Are headaches occurring at MAX of 8 attacks per day OR MIN of 1 attack every other day?
Yes
No
PREVENTATIVE TREATMENT
ACUTE TREATMENT
Was there trial and failure with verapamil?
Yes
No
Was there trial and failure with sumatriptan (nasal
or subcutaneous)?
Yes
No
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.
Effective: 12/03/2020 C16835-C 09-2020
Proprietary
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Pharmacy Prior Authorization Request Form Calcitonin Gene-Related Peptide (Mercy Care)

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Completed 31 July 2021

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