Fillable Pharmacy Prior Authorization Request Form Gonadotropin Releasing Hormone (Mercy Care)

Fill Online, Printable, Fillable, Blank Pharmacy Prior Authorization Request Form Gonadotropin Releasing Hormone (Mercy Care) Form

Use Fill to complete blank online MERCY CARE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Pharmacy Prior Authorization Request Form Gonadotropin Releasing Hormone (Mercy Care)

On average this form takes 32 minutes to complete

The Pharmacy Prior Authorization Request Form Gonadotropin Releasing Hormone (Mercy Care) form is 3 pages long and contains:

  • 2 signatures
  • 29 check-boxes
  • 105 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Mercy Care forms online.

BROWSE MERCY CARE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Effective: 04/01/2020 C4418-A, C4588-A, C7007-A, C7010-A, C7834-A, C8044-A, C11883-A 12-2019 & 01-2020 1 of 3
Proprietary
Fax completed prior authorization request form to 800-854-7614 or submit Electronic Prior Authorization through
CoverMyMeds® or SureScripts.
All requested data m ust be provided. Incomplete forms or forms without the chart notes will be ret urned
Pharmacy Coverage
Gu
idelines are available at
www.mercycareaz.org/providers/completecare-forproviders/pharmacy
Gonadotropin Releasing Hormone Analogs
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 s upport diagnosis
Member Information
Member Name (first & last):
Date of Birth:
Gender:
Male
Female
Height:
Member ID:
City:
State:
Weight:
Provider Name (first & last):
Specialty:
NPI#
DEA#
Office Address:
City:
State:
Zip Code:
Office Contact:
Office Phone
Office Fax:
Pharmacy Name:
Pharmacy Phone:
Pharmacy Fax:
Firmagon
☐ ☐ ☐ ☐
☐
☐ ☐ ☐ ☐ ☐
☐
☐
☐ ☐
Leuprolide acetate
Lupaneta Pack
Lupron Depot
Lupron Depot-PED
Eligard
Orilissa
Trelstar
Triptodur
Vantas
Synarel
Supprelin LA
Zoladex
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:
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:
_____________________________________________________
Was there trial AND failure with at least ONE
formulary hormonal cycle control agent OR
medroxyprogesterone, in COMBO with NSAID?
Yes
No
Does member have severe disease
or recurrent symptoms?
Yes
No
Treatment is for recurrence after initial
course of therapy?
Yes
No
Total duration of treatment for both initial AND
recurrent symptoms will not be longer than 12
months?
Yes
No
Will add-back therapy with norethindrone be used concurrently?
Yes
No
Is requested medication prescribed to improve
Yes
No
Was there trial AND failure with iron
Yes
No
click to sign
signature
click to edit
Effective: 04/01/2020 C4418-A, C4588-A, C7007-A, C7010-A, C7834-A, C8044-A, C11883-A 12-2019 & 01-2020 2 of 3
Proprietary
anemia and/or reduce uterine size prior to planned
surgical intervention?
to correct anemia?
Is requested medication prescribed to thin endometrium prior to planned endometrial ablation OR hysterectomy
within next 4-8 weeks?
Yes
No
Was an MRI OR CT Scan performed to rule out
brain lesions OR tumors?
Yes
No
Does member have onset of secondary
sexual characteristics earlier than 8
years in females AND 9 years in males?
Yes
No
Was there response to GnRH stimulation test (or
other labs to support CPP, such as LH level,
estradiol AND testosterone level)?
Yes
No
Was bone age advanced 1 year beyond
chronological age?
Yes
No
Was there clinical response to treatment (for example, pubertal slowing or decline, height velocity, bone age,
estradiol AND testosterone level)?
Yes
No
Is member at least 18 years of age AND premenopausal at time of diagnosis?
Yes
No
Member cannot tolerate OR does not respond
to cytotoxic regimens?
Yes
No
Is drug requested being used for post-
operative management?
Yes
No
Does member have androgen receptor
positive recurrent disease with distant
metastases?
Yes
No
Is there a performance status score of 0 – 3
by ECOG standards?
Yes
No
Was medication prescribed by Pediatric
Endocrinologist that collaborated care with a
Mental Health Provider?
Yes
No
Does member show persistent, well-
documented diagnosis of gender non-
conformity OR dysphoria that worsened with
puberty?
Yes
No
Does member exhibit signs of puberty with
minimum Tanner stage 2?
Yes
No
Has member made a fully informed decision
AND given consent, AND parent/guardian
consents to treatment OR member has been
emancipated?
Yes
No
Are member’s comorbid conditions reasonably
controlled?
Yes
No
Was member educated on any
contraindications AND side effects to
therapy?
Yes
No
Was member informed of fertility preservation options prior to treatment?
Yes
No
Are there lab results to support response to treatment (for example, FSH, LH, weight, height, tanner stage, bone
age)?
Yes
No
Was requested medication prescribed by
Endocrinologist that collaborated care with a
Mental Health Provider?
Yes
No
Does member show persistent, well-
documented diagnosis of gender dysphoria /
incongruence?
Yes
No
Does member have capacity to make a fully
informed decision and consents to treatment?
Yes
No
Are mental health concerns, if present,
reasonably well controlled?
Yes
No
Was member informed of fertility preservation options prior to treatment?
Yes
No
Are there lab results to support response to treatment (for example, FSH, LH, weight, height, tanner stage, bone
age)?
Yes
No
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 check the s tatus of a request.
Effective: 04/01/2020 C4418-A, C4588-A, C7007-A, C7010-A, C7834-A, C8044-A, C11883-A 12-2019 & 01-2020
Proprietary
________________________________
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Pharmacy Prior Authorization Request Form Gonadotropin Releasing Hormone (Mercy Care)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 31 July 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document