Fillable Pharmacy Prior Authorization Request Form Emflaza (Mercy Care)

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Pharmacy Prior Authorization Request Form Emflaza (Mercy Care)

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

  • 2 signatures
  • 2 check-boxes
  • 63 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
Emflaza
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 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
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, please specify:
New
request
Continuation of
therapy ONLY:
Has there been clinical benefit from
therapy documented as improvement
in baseline motor milestone scores?
Yes
No
Will Emflaza be given
concurrently with live
vaccinations?
Yes
No
Does member have active infection
(including HBV)?
Yes
No
If member has history of
HBV infection,
will provider
monitor for HBV reinfection?
Yes
No
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
Did genetic testing demonstrate mutation in
dystrophin gene?
Yes
No
Did muscle biopsy show total absence of
dystrophin OR abnormal dystrophin?
Yes
No
Is creatine kinase at least 10 times ULN?
Yes
No
Was there a trial of prednisone for at least
6 months?
Yes
No
Was there unmanageable AND clinically significant weight gain / obesity OR psychiatric / behavioral issues
(abnormal behavior, aggression, or irritability) as result of trial of prednisone?
Yes
No
Baseline motor milestone score was completed by one of the following:
6-minute walk test (6MWT)
North Star Ambulatory Assessment (NSAA)
Motor Function Measur
e (MFM)
Hammersmith Functional Motor Scale (HFMS)
Additional information the prescribing provider feels is important to this review. Please specify below or submit medical records.
Effective: 06/08/2020 C12580-A 02-2020 Page 1 of 2
Proprietary
click to sign
signature
click to edit
Page 2 of 2
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.
E
ffective: 06/08/2020 C12580
-A 02-2020
Proprietary
click to sign
signature
click to edit
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Pharmacy Prior Authorization Request Form Emflaza (Mercy Care)

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Completed 31 July 2021

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