Fillable Pharmacy Prior Authorization Request Form Cytokines and Cell (Mercy Care)

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Pharmacy Prior Authorization Request Form Cytokines and Cell (Mercy Care)

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  • 55 check-boxes
  • 198 other fields

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Effective: 06/08/2020 Page 1 of 4
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. Incomp
lete forms or forms without the chart notes will be returned
Pharmacy Coverage Guidelines are available at www.mercycareaz.org/providers/completecare-forproviders/pharmacy
Cytokines and Cell Adhesion Molecule (CAM) 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
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
Preferred Agents:
Enbrel
Humira
Otezla
Xeljanz IR
Non-Preferred
Agents:
Actemra
Arcalyst
Cosentyx
Taltz
Ilaris
Ilumya
Kineret
Siliq
Orencia
Renflexis
Tremfya
Tysabri
Olumiant
Remicade
Xeljanz XR
Cimzia
Skyrizi
Simponi Aria
Simponi
Stelara
Inflectra
Other, specify:
Medication request is NOT for an FDA- approved, or
compendia-supported diagnosis (circle one):
Yes No
Diagnosis:
ICD-10 Code:
Are there any contraindications to formulary medications?
Yes
No(if yes, specify):
New
request
Continuation of
therapy
Directions for Use:
Strength:
Dosage Form:
Quantity:
Day Supply: Duration of Therapy/Use:
What medication(s) has the member tried and failed for this diagnosis? Please specify below.
Turn-
Around Time for Review
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
General Authorization Criteria
Is member on another Cytokine or Cell Adhesion Molecule (CAM) Antagonist?
Yes
No
Is request for Anti-Tumor Necrosis Factor?
Yes
No Does member have NYHA class III
OR IV CHF?
Yes
No
N/A
Is request for Anti-Tumor Necrosis Factors such as Stelara, Xeljanz, Xeljanz XR, Kineret, Actemra, Ilaris
OR Orencia?
Yes
No
Was a screen completed for Hepatitis B?
Yes
No Does member have active OR
chronic Hepatitis B?
Yes
No
If member has active OR chronic Hepatitis B, is member receiving appropriate antiviral treatment?
Yes
No
N/A
Was member evaluated AND given appropriate vaccinations, as recommended per CDC, for risk factors?
Yes
No
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signature
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Effective: 06/08/2020 Page 2 of 4
Proprietary
Was member
screened for TB?
Yes
No
If screening was positive for latent TB, was treatment
received for latent TB?
Yes
No
N/A
Is request for
Entyvio OR Tysabri?
Yes
No
Is use Monotherapy AND not in combination with
antineoplastic, immunosuppressive OR immunomodulating
agents (AZA, 6-MP, cyclosporine, MTX, TNF inhibitors)
Yes
No
N/A
Additional Criteria Based on Indication:
Rheumatoid Arthritis
Was there inadequate response to 3-
month trial of MTX?
Yes
No
Was there intolerance OR contraindication to MTX?
Yes
No
Were SSZ, LEF or HCQ used due to
intolerance OR contraindication to MTX?
Yes
No
Will requested medication be used concurrently with
MTX or another non-biologic DMARD such as SSZ,
LEF or HCQ?
Yes
No
Systemic Juvenile Idiopathic Arthritis
Does member have ACTIVE SYSTEMIC FEATURES such as
fever, evanescent rash, lymphadenopathy, hepatomegaly,
splenomegaly OR serositis?
(circle one): Yes No
Is synovitis in ONE OR MORE JOINTS despite 3 months treatment with
MTX OR LEF? (circle one):
Yes No
Check if ONE of
the following apply:
There are ACTIVE SYSTEMIC FEATURES (fever, evanescent rash, lymphadenopathy, hepatomegaly,
splenomegaly OR serositis) AND synovitis is in at least ONE JOINT.
There are NO ACTIVE SYSTEMIC FEATURES (fever, evanescent rash, lymphadenopathy, hepatomegaly,
splenomegaly OR
serositis) AND synovitis is in ONE OR MORE JOINTS despite 3 months treatment with MTX OR
LEF.
There are ACTIVE SYSTEMIC FEATURES (fever, evanescent
rash, lymphadenopathy, hepatomegaly
, splenomegaly, or serositis)
(circle one): Yes No
Synovitis is in ONE OR MORE JOINTS despite ONE-month treatment
with Kineret OR Actemra AND MTX OR LEF (circle one):
Yes No
Polyarticular Juvenile Idiopathic Arthritis
Was there inadequate response to 3-months trial
with MTX?
Yes
No Was there an intolerance OR
contraindication to MTX?
Yes
No
N/A
Was there trial with SSZ OR LEF for 3 months?
Yes
No
N/A
Oligoarticular Juvenile Idiopathic Arthritis
Is disease duration
> 6 months?
Yes
No
Was there documented inadequate response
OR intolerable side effect with 2 NSAIDs?
Yes, indicate drug:
No
Was there contraindication to
NSAIDs?
Yes
No
N/A
Was there inadequate response OR intolerable
side effect to 3-month trial with MTX?
Yes
No
Was there documented trial of LEF OR SSZ for 3 months?
Yes
No
N/A
Cryopyrin-Associated Periodic Syndromes
Indicate if ONE of the following
subtypes is present:
Familial Cold Auto
Inflammatory Syndrome
Muckle-Wells syndrome
Neonatal onset multi-system
inflammatory disease
Was there 3-months trial with Kineret?
Yes
No
N/A
Familial Mediterranean Fever
Was there inadequate response, intolerance OR
contraindication to colchicine at MAX indicated dose?
Yes
No
Giant Cell Arteritis
Was there inadequate response with glucocorticoids
(prednisone, methylprednisolone)?
Yes
No
Was there intolerance OR
contraindication to glucocorticoids?
Yes
No
If member had intolerance OR contraindication to
glucocorticoids, was there TRIAL with MTX OR
cyclophosphamide?
Yes
No
N/A
Will medication be used in
combination with tapering
course of glucocorticoids
Yes
No
Ankylosing Spondylitis
Was there inadequate response to ONE-
month trial of TWO NSAIDs?
Yes
No
Is there contraindication OR
intolerance to oral NSAIDs?
Yes
No
N/A
Psoriatic Arthritis
Does member have ACTIVE Psoriatic Arthritis?
Yes
No
Was there inadequate response to 3-
months trial with MTX?
Yes
No
Was there intolerance OR
contraindication to MTX?
Yes
No
N/A
Was there 3-month trial of SSZ OR LEF?
Yes
No
Is disease predominantly AXIAL OR ACTIVE ENTHESITIS / DACTYLITIS?
Yes
No
Was there inadequate response to ONE-
month trial of 2 NSAIDs?
Yes
No
Was there contraindication OR
intolerance to oral NSAIDs?
Yes
No
N/A
Plaque Psoriasis
Was there inadequate response to
MTX OR cyclosporine for ≥3 months?
Yes
No
Was there intolerance OR contraindication
to MTX OR cyclosporine for ≥3 months?
Yes
No
N/A
Is >10% BSA affected?
Yes
No Is <10% BSA affected BUT involves sensitive areas
such as hands, feet, face OR genitals?
Yes
No
Page 3 of 4
Is Psoriasis Area and Severity Index
score >10?
Yes
No Was phototherapy PUVA, UVB
ineffective?
Yes
No
For Siliq
ONLY:
Is there history of a prior suicide attempt, bipolar disorder OR depressive disorder? Yes No
Was a mental health evaluation completed by prescriber OR psychiatrist? Yes No
Ulcerative Colitis
STEROID
DEPENDENT
A relapse occurred within 3-months of stopping
glucocorticoids (circle one):
Yes No
There is Inability to taper steroids to acceptable dose after
3 months W/O having symptom recurrence:(circle one):
Yes No
STEROID
REFRACTORY
Inadequate response OR intolerable side effect to IV
glucocorticoids after 7-10 days (circle one):
Yes No
Inadequate response OR intolerable side effect to oral
prednisone ≥40mg per day after 30 days (circle one):
Yes No
Crohn’s Disease
STEROID
DEPENDENT
A relapse occurred within 3-months of stopping
glucocorticoids (circle one):
Yes No
There was inadequate response OR intolerable side effect,
with 3-month trial of 6-MP OR AZA OR injectable MTX
(circle one): Yes No
There is inability to taper steroids to acceptable dose
after 3 months W/O having symptom recurrence
(circle one): Yes No
There was contraindication to 6-MP, AZA, AND injectable
MTX (circle one):
Yes No
STEROID
REFRACTORY
There was inadequate response OR intolerable side
effect to IV glucocorticoids after 7-10 days (circle one):
Yes No
There was inadequate response OR intolerable side effect
to oral prednisone ≥40mg per day after 30 days
(circle one): Yes No
Hidradenitis Suppurativa (Acne Inversa)
Does member have moderate to severe
disease (Hurley stage II-III)?
Yes
No Was there trial AND failure of 90-day
treatment with oral antibiotics (doxycycline,
minocycline OR clindamycin with rifampin)?
Yes
No
Behçet’s Disease
Does member have ACTIVE RECURRENT
oral ulcers?
Yes
No Was there trial AND failure with ONE Non-
Biologic DMARD (MTX, LEF, SSZ OR HCQ)?
Yes
No
Uveitis
Was intermediate,
posterior OR pan uveitis
caused by infection?
Yes No There was inadequate
response OR intolerable
side effect with following:
cyclosporine tacrolimus Corticosteroids
MTX
AZA
MMF
Are medications such as corticosteroids, MTX, AZA, MMF, cyclosporine, AND tacrolimus are NOT appropriate?
Yes
No
Cytokine Release Syndrome
Is diagnosis grade 3 OR 4, severe OR life-threatening due to chimeric antigen receptor-T cell therapy?
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: 06/08/2020
Proprietary
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Pharmacy Prior Authorization Request Form Cytokines and Cell (Mercy Care)

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Completed 31 July 2021

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