Fillable Pharmacy Prior Authorization Request Form Interleukin-5 Antagonists (Mercy Care)

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Pharmacy Prior Authorization Request Form Interleukin-5 Antagonists (Mercy Care)

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The Pharmacy Prior Authorization Request Form Interleukin-5 Antagonists (Mercy Care) form is 2 pages long and contains:

  • 2 signatures
  • 12 check-boxes
  • 60 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.
A
ll 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
Interleukin-5 Antagonists
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
Are there any contraindications to formulary medications? Yes No
If yes, please specify:
New
request
Continuation
of therapy
Continuation of therapy ONLY (check that apply):
Member response to treatment
Tapering of oral corticosteroid
dose
Cinqair
Fasenra
Nucala
Directions for Use:
Strength:
Dosage Form:
Quantity: Day Supply: Duration of Therapy/Use:
Medication request is NOT for an FDA approved, or
compendia sup
ported diagnosis (circle one): Yes No
Diagnosis:
ICD-10 Code:
What medication(s) have been tried and failed for this diagnosis?
Please specify:
Turn-Around Time for Review
Standard – (24 hours)
Urgent – If waiting 24 hours for standard decision could seriously harm life, health, or ability to
regain maximum function, you can ask for an expedited decision.
Signature:
Clinical Information
Severe Eosinophilic Asthma
Lab results to support ONE of the
following blood eosinophil
counts:
≥
150 cells/mcL within 6
weeks of dosing (Nucala,
Fasenra)
≥
300 cells/mcL at any time in
past 12 months (Nucala,
Fasenra)
≥
400 cells/mcL
at baseline
(Cinqair)
Member has been compliant with ONE of the
following regimens for at least 3 months:
Medium or high ICS + LABA Medium or high ICS + Other
controller medications (LTRA or
theophylline) if intolerant to LABA
Asthma symptoms are poorly controlled on
ONE of the above regimens, as defined by
ANY of the following:
At least TWO exacerbations in
last 12 months requiring
additional medical treatment
(systemic corticosteroids, ER
visits OR hospitalization)
Daily use of
rescue
medications
(SABA)
Nighttime
symptoms
occurring more
than once per
week
Does member have history of exacerbations?
Yes
No
Did member have a TWO-month trial with
Yes
No
Effective: 06/28/2021 C9729-A 01-2021 Page 1 of 2
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_______ __ _________
tiotropium (requires PA)?
Will medication be used in combination with Xolair or another Interleukin-5 (IL-5) inhibitor?
Yes
No
Eosinophilic Granulomatosis with Polyangiitis (EGPA)
Has members had diagnosis for at least 6
months WITH history of relapsing or
refractory disease?
Yes No Has member been on stable dose of
ORAL prednisolone OR prednisone ≥7.5
mg/day BUT ≤50 mg/day for at least 4
weeks?
Yes No
Is the Five Factor Score (FFS) < 2?
Yes
No
Was there trial and failure OR
contraindication to cyclophosphamide?
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 medi
cal 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.
Effec
tive: 06/28/2021 C9729-A 01
-2021
Page 2 of 2
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Pharmacy Prior Authorization Request Form Interleukin-5 Antagonists (Mercy Care)

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Completed 31 July 2021

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