Fillable Pharmacy Prior Authorization Request Form Interferons (Mercy Care)

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Pharmacy Prior Authorization Request Form Interferons (Mercy Care)

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

  • 2 signatures
  • 24 check-boxes
  • 76 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
Interferons
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
☐ Alferon N
☐ Intron A
☐ Pegasys
☐ Actimmune
☐ Other, please specify:
Are there any contraindications to formulary medications?
Yes
No
If yes, please specify:
New
request
Continuation
of therapy
request
What medication(s) has member tried and failed for this diagnosis?
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
Chronic Hepatitis B
Current lab reports to
support the following:
Documentation ALT ≥2
times ULN
Documentation of elevated
Hepatitis B Virus DNA level
Above 2,000 IU/mL Hepatitis B e-
antigen negative
Significant histologic
disease
Above 20,000 IU/mL Hepatitis B
e-antigen positive
Is there evidence of compensated Liver disease?
Yes
No
Renewal ONLY:
Is lab report supportive of Hepatitis B e-antigen
POSITIVE?
Yes
No
Is lab report supportive of Hepatitis B e-
antigen NEGATIVE?
Yes
No
Follicular Non-Hodgkin’s Lymphoma (Stage III/IV)
Will requested medication be given in conjunction with anthracycline-containing combination chemotherapy?
Yes
No
Acquired Immune Deficiency Syndrome (AIDS)-Related Kaposi's Sarcoma
Confirm member age per above:
Confirm provider specialty per above:
Hairy-Cell Leukemia
Did member have less than a complete response to cladribine or pentostatin?
Yes
No
Effective: 8/18/2020 C6637-A, C6638-A, C11918-A 05-2020 Page 1 of 2
Proprietary
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Page 2 of 2
Was there a relapse after <2 years of demonstrating a complete response to cladribine OR pentostatin?
Yes
No
Renewal ONLY:
Is there evidence of disease progression?
Yes
No
Chronic Granulomatous Disease
Confirm member age per above:
Confirm provider specialty per above:
Renewal ONLY:
Is there evidence of disease progression?
Yes
No
Malignant Osteopetrosis
Confirm diagnosis per above:
Confirm provider specialty per above:
Renewal ONLY:
Is there evidence of disease progression?
Yes
No
Condylomata acuminata - Genital or Venereal Warts
Is requested medication for intra-lesional use?
Yes
No
Are the lesions small and limited in number?
Yes
No
Did member have trial and failure with TOPICAL treatments (for example, imiquimod cream, podofilox)?
Yes
No
Was there trial and failure with a surgical technique (for example, cryotherapy, laser surgery, electrodessication,
surgical excision)?
Yes
No
Renewal ONLY:
Was there at least 3 months between treatments, unless lesions grow, or new lesions appear?
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.
Effe
ctive: 8/18/2020 C6637-A, C6638-A, C11918-A 05-2020
Proprietary
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click to edit
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Pharmacy Prior Authorization Request Form Interferons (Mercy Care)

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Completed 31 July 2021

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