Fillable Pharmacy Prior Authorization Request Form Idiopathic Pulmonary Fibrosis (Mercy Care)

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Pharmacy Prior Authorization Request Form Idiopathic Pulmonary Fibrosis (Mercy Care)

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

  • 2 signatures
  • 12 check-boxes
  • 73 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.
Al
l 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
Idiopathic Pulmonary Fibrosis
Pharmacy Prior Authorization Request Form
Do not copy for future use. Forms are updated frequently.
REQUIRED: Office notes, labs an
d 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 Phone
Office Fax:
Dispensing Pharmacy Information
Pharmacy Phone:
Pharmacy Fax:
Requested Medication Information
Esbriet
Ofev
Other, please specify:
What medication(s) has member tried and failed for this diagnosis?
Please specify:
Are there any contraindications to formulary medications? Yes No
If yes, please specify:
New
request
Continuation
of therapy
request
Medication request is NOT for an FDA approved, or
compendia supported diagnosis (circle one):
Yes No
Diagnosis: ICD-10 Code:
Directions
for Use: Strength: Dosage Form:
Quantity: Day Supply: Duration of Therapy/Use:
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
Is FVC
≥
40% predicted? Yes No Is Carbon Monoxide Diffusion Capacity
≥30%
Yes No
Were baseline LFTs completed?
Yes
No
Is member a current smoker?
Yes
No
Have other known causes of interstitial lung disease been ruled out?
(for example, domestic AND occupational environmental exposures, connective tissue disease OR drug toxicity)
Yes
No
OFEV
ONLY:
Is member a female of
reproductive potential?
Yes
No
Did the female member have
a NEGATIVE pregnancy test?
Yes
No
N/A
☐ Idiopathic Pulmonary Fibrosis
Effective: 06/28/2021 C7837-A 01-2021 Page 1 of 2
click to sign
signature
click to edit
☐
The diagnosis of idiopathic pulmonary fibrosis is
confirmed by ONE of the following:
High resolution computed
tomography demonstrating usual
interstitial pneumonia
Surgical lung biopsy with
usual interstitial pneumonia
☐ Chronic Fibrosing of Interstitial Lung Disease – OFEV ONLY
Does member have relevant fibrosis (> 10% fibrotic
features)?
Yes
No
Does member have clinical signs of progression?
Check ALL that apply
FVC decline ≥10%
FVC decline ≥5% < 10% with worsen
ing
symptoms or imaging
Worsening symptoms AND
imaging in
the
24
month
s prior to screening
☐ Systemic Sclerosis-Associated Interstitial Lung Disease - Ofev only
Was onset of disease < 7 years (1
st
non-
Raynaud symptom) ?
Yes
No
Was fibrosis ≥10% on HRCT scan within last
12 months?
Yes
No
Renewal Requests ONLY:
Does member have a stable FVC?
Yes
No
Are LFTs being monitored?
Yes
No
Is member a current smoker? Yes No Has member been compliant and adherent
to treatment?
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 med
ical justification are required
Standard turnaround time is 24 hours. You can call 800-624-3879 to check the status of a request.
E
ffective: 06/28/2021 C7837-A 01-2021
Page 2 of 2
☐
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Pharmacy Prior Authorization Request Form Idiopathic Pulmonary Fibrosis (Mercy Care)

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Completed 31 July 2021

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