Fillable Pharmacy Prior Authorization Request Form Erythropoiesis Stimulating Agents (Mercy Care)

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Pharmacy Prior Authorization Request Form Erythropoiesis Stimulating Agents (Mercy Care)

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

  • 2 signatures
  • 18 check-boxes
  • 91 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
Erythropoiesis Stimulating Agents
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:
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 Agent:
Retacrit
Non-Preferred Agents:
Epogen
Procrit
Aranesp
Mircera
Other,
please specify:
For non-preferred agents ONLY: Did member have trial and failure with Retacrit?
Yes
No
Are there any contraindications to formulary medications?
Yes
No
If yes, please specify:
New
request
Continuation of
therapy request
ICD-10 Code:
Diagnosis:
Medication request is NOT for an FDA approved, or compendia-
supported diagnosis (circle one):
Yes No
Directions for Use:
Strength:
Dosage Form:
Quantity:
Day
Supply:
Duration of Therapy/Use:
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
Does member have uncontrolled HTN?
Yes
No
Is reticulocyte Hgb content >29 pg?
Yes
No
Is serum ferritin ≥100 ng/mL AND transferrin saturation (iron saturation) ≥20%?
Yes
No
Additional Criteria Based on Indication
Anemia due to Chronic Kidney Disease
Is Hgb <10 g/dL within the last 2 weeks?
Yes
No
Renewal Request ONLY
Is member an ADULT on HD with Hgb <11
g/dL within last 2 weeks?
Yes
No
Is member an ADULT NOT on HD with Hgb
<10 g/dL within last 2 weeks?
Yes
No
Is member a PEDIATRIC with Hgb <12 g/dL within last 2 weeks?
Yes
No
Anemia due to Cancer Chemotherapy
Is anemia due to concomitant
myelosuppressive chemotherapy?
Yes
No
Is diagnosis non-myeloid malignancy such
as solid tumor AND expected outcome is
Yes
No
Effective: 04/01/2020 C14411-A, C15562-A Page 1 of 2
Proprietary
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Page 2 of 2
not a cure?
Is there a minimum of TWO additional months
of planned chemotherapy?
Yes
No
Was Hgb <10 g/dL within last 2 weeks?
Yes
No
Renewal Request ONLY
Is Hgb <11 g/dL within last 2 weeks?
Yes
No
Anemia with HIV Member Receiving Zidovudine
Is Zidovudine dose ≤4200 mg/week?
Yes
No
Are erythropoietin levels ≤ 500 IU/L?
Yes
No
Was Hgb <10 g/dL within the last 2 weeks?
Yes
No
Renewal ONLY
Was Hgb <11 g/dL within the last 2 weeks?
Yes
No
Reducing Transfusions in Elective Non-Cardiac Non-Vascular Surgery
Was Hgb >10 g/dL AND ≤13 g/dL within 30
days prior to planned surgery date?
☐
Yes
No
Is member at high risk for perioperative
blood loss?
Yes
No
Is member unable or unwilling to donate autologous blood preoperatively?
Yes
No
Anemia Associated with Myelodysplastic Syndrome
Are recent erythropoietin levels ≤500 IU/L?
Yes
No
Was Hgb <10 g/dL within last 2 weeks?
Yes
☐
No
Renewal Request ONLY
Was hemoglobin <12 g/dL within last 2 weeks?
Yes
☐
No
Anemia in Hepatitis C
Is member receiving combination therapy with
ribavirin AND interferon alpha?
Yes
No
Was Hgb <12 g/dL within last 2 weeks?
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.
Effecti
ve: 04/01/2020 C14411-A, C15562-A
Proprietary
click to sign
signature
click to edit
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Pharmacy Prior Authorization Request Form Erythropoiesis Stimulating Agents (Mercy Care)

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Completed 31 July 2021

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