Fillable Pharmacy Prior Authorization Request Form Multiple Sclerosis (MS) (Mercy Care)

Fill Online, Printable, Fillable, Blank Pharmacy Prior Authorization Request Form Multiple Sclerosis (MS) (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 Multiple Sclerosis (MS) (Mercy Care)

On average this form takes 50 minutes to complete

The Pharmacy Prior Authorization Request Form Multiple Sclerosis (MS) (Mercy Care) form is 4 pages long and contains:

  • 2 signatures
  • 67 check-boxes
  • 159 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
 
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 G
uidelines are available at www.mercycareaz.org/providers/completecare-
forproviders/pharmacy
Multiple Sclerosis (MS) 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 Agents:
☐
☐
☐
☐
☐
☐
Copaxone 20mg
Betaseron
Avonex
Gilenya
Glatopa 40mg
Rebif / Rebidose
Non-Preferred Agent:
Other, Please Specify:
Was there inadequate response, intolerable side effects OR contraindication to 2 formulary
agents, one of which was an interferon or glatiramer acetate?
Yes
No
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 the diagnosis?
Are there any contraindications to formulary medications?
Yes
No
If yes, please specify:
Initial
request
Continuation
of therapy
☐ CONTINUATION of therapy requests ONLY:
Was documentation AND lab results
submitted support
ing response to TX AND no
serious toxicity as result of TX?
Yes
No
Are the required initial therapy tests completed
AND
continuously monitored as clinically
appropriate? (LVEF, CBC, ANC, ECG,
immunoglobuli
ns level, contraception use for
females of reproductive potential)
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
Have other disease modifying MS therapies (not including Ampyra) been D/C’d OR have been D/C’d?
Yes
No
INJECTABLE AGENTS
Copaxone 40mg
Avonex
Glatopa 20mg glatiramer acetate
Extavia
Rebif/Rebidose
Does member have clinically isolated syndrome
suggestive of MS (experienced 1
st
clinical episode
AND MRI features consistent with MS)?
Yes
No
Is diagnosis of relapsing form of MS
(relapsing-remitting OR active
secondary progressive MS)?
Yes
No
Effective: 03/03/2021 C4447-A 01-2021 Page 1 of 4
Proprietary
click to sign
signature
click to edit
Effective: 03/03/2021 C4447-A 01-2021 Page 2 of 4
Proprietary
Betaseron
Plegridy
Does member have clinically isolated syndrome
suggestive of MS (experienced 1
st
clinical episode
AND MRI features consistent with MS)?
Yes
No
Is diagnosis of relapsing form of MS
(relapsing-remitting OR active
secondary progressive MS)?
Yes
No
ORAL AGENTS
Aubagio
Is diagnosis clinically isolated syndrome
suggestive of MS (experienced 1
st
clinical
episode AND MRI features consistent with
MS)?
Yes
No
Is diagnosis relapsing form of MS
(relapsing-remitting OR active secondary
progressive MS)?
Yes
No
Is member FEMALE of reproductive potential?
Yes
No
Is FEMALE member pregnant?
Yes
No
N/A
Will FEMALE member be using effective contraception during treatment?
Yes
No
N/A
The following LABS have been completed within last SIX months:
☐
CBC
LFTs and bilirubin Tuberculin skin test ☐
☐
Bafiertam
Is the diagnosis relapsing form of MS (for example, relapsing-remitting or active secondary progressive MS)?
Yes
No
Does member have clinically isolated syndrome suggestive of MS (for example, experienced 1
st
clinical episode and
MRI features consistent with MS)?
Yes
No
Was baseline (within 3 months) MRI scan obtained prior to starting TX course due to risk of PML?
Yes
No
Is there history of either varicella vaccine series OR zoster vaccine series if 50 years of age or older?
Yes
No
The following labs have been completed within past 6 months:
CBC and lymphocyte count
LFTs and bilirubin levels
☐
Gilenya
Is diagnosis clinically isolated syndrome suggestive of MS
(experienced 1
st
clinical episode AND MRI features
consistent with MS)?
Yes
No
Is diagnosis of relapsing form of
MS (relapsing-remitting OR active
secondary progressive MS)?
Yes
No
Labs have been completed within past 6 months:
☐
☐
☐
☐
CBC LFTs and bilirubin ECG Ophthalmic examination
Is there history of either varicella vaccine series OR zoster vaccine series if 50 years of age or older?
Yes
No
Documented history of ANY of the following:
☐
☐
☐
☐
MI - Unstable Angina – stroke – TIA - Decompensated HF requiring hospitalization OR
Class III/IV HF within past 6 months
Corrected QTc ≥500 msec
HX of Mobitz type II (2
nd
OR 3
rd
degree AV block) OR sick sinus syndrome, unless there
is a pacemaker
Treatment with Class Ia OR Class III anti-arrhythmic drugs
Mayzent
Is diagnosis clinically isolated syndrome suggestive of MS
(experienced 1
st
clinical episode AND MRI features
consistent with MS)?
Yes
No
Is diagnosis of relapsing form of
MS (relapsing-remitting OR active
secondary progressive MS)?
Yes
No
Was member tested for CYP2C9 variants to
determine CYP2C9 genotype?
Yes
No
Is member positive for CYP2C9*3/*3?
Yes
No
Labs have been completed within past 6 months:
☐ CBC
☐
☐
☐
LFTs and bilirubin ECG Ophthalmic exam
Is there history of either varicella vaccine series OR zoster vaccine series if 50 years of age or older?
Yes
No
Documented history of ANY of the following:
☐
☐
MI - Unstable Angina – Stroke – TIA - Decompensated HF requiring hospitalization OR
Class III/IV HF within past SIX months
History of Mobitz type II (2
nd
OR 3
rd
degree AV block) OR sick sinus syndrome, unless
member has pacemaker
Mavenclad
Does member have clinically isolated syndrome
suggestive of MS
(experienced 1
st
clinical episode AND have MRI features
consistent with MS)?
Yes
No
Is diagnosis of relapsing form of
MS (relapsing-remitting OR active
secondary progressive MS)?
Yes
No
Was baseline (within 3 months)
MRI scan obtained prior to starting
TX course due to risk of PML?
Yes
No
Is there infection with HIV AND active chronic infections
(Hepatitis OR TB) OR breastfeeding (during TX OR for
10 days after last dose)?
Yes
No
Is member a FEMALE of reproductive potential?
Yes
No
Is the FEMALE
member pregnant?
Yes
No
N/A
Will the FEMALE member be using effective contraception during treatment?
Yes
No
N/A
Has the member received the lifetime maximum of 2 courses (4 cycles) of therapy?
Yes
No
Zeposia
Is the diagnosis of relapsing form of MS (for ex relapsing-remitting or active secondary progressive MS)?
Yes
No
Is there clinically isolated syndrome suggestive of MS (for example experienced a 1
st
clinical episode and have
MRI features consistent with MS?
Yes
No
Any ONE of the following is present:
History (within last 6 months) of MI, UA, stroke, TIA, decompensated heart failure requiring
hospitalization OR NYHA Class III/IV heart failure
History OR presence of Mobitz Type II 2
nd
OR 3
rd
degree AV block, sick sinus syndrome OR
sino-atrial block (unless there is a functioning pacemaker)
Severe untreated sleep apnea
ALL the following labs were completed within the last 6 months:
CBC
LFTs and bilirubin levels
ECG
Ophthalmic examination
Is there HX of either varicella vaccine series OR zoster vaccine series if 50 years of age or older?
Yes
No
Was baseline (past 3 months) MRI scan obtained prior to starting TX course due to risk of PML?
Yes
No
Is member a FEMALE of reproductive
potential?
Yes
No
Is the FEMALE member
pregnant?
Yes
No
N/A
Will the FEMALE member be using effective contraception during treatment?
Yes
No
N/A
Tecfidera
Vumerity
Does member have clinically isolated syndrome
suggestive of MS (experienced 1
st
clinical episode
AND have MRI features consistent with MS)?
Yes
No
Is diagnosis of relapsing form of MS
(relapsing-remitting OR active
secondary progressive MS)?
Yes
No
The following LABS have been completed within last SIX months:
☐
CBC
☐
LFTs and bilirubin
INFUSIONS
Ocrevus
Was member screened for Hepatitis B?
Yes
No
Does member have active Hepatitis B infection?
Yes
No
Does member have clinically isolated
syndrome suggestive of MS
(experienced 1
st
clinical episode AND
have MRI features consistent with MS)?
Yes
No
Is diagnosis of relapsing form of MS (relapsing-
remitting OR active secondary progressive MS)?
Yes
No
Is diagnosis of Primary-Progressive
MS?
Yes
No
Lemtrada
Is diagnosis of relapsing form of MS
(relapsing-remitting OR active
secondary progressive MS)?
Yes
No
Will treatment exceed FIVE days the first year, AND
THREE days the 2nd year?
Yes
No
Is the member infected with HIV?
Yes
No
The following been completed prior to starting TX?
☐
CBC
☐
Necessary immunizations
☐
Serum creatinine levels
☐
History of either varicella vaccine series OR zoster vaccine series if 50 years of
age or older
☐
Screened for TB AND If screening positive, TX
was received
☐
Thyroid Function Test
Tysabri
Is diagnosis clinically isolated syndrome
suggestive of MS (experienced 1
st
clinical
episode AND MRI features consistent w/MS)?
Yes
No
Is diagnosis of relapsing form of MS
(relapsing-remitting OR active secondary
progressive MS)?
Yes
No
Has anti-JCV antibody test (ELISA [enzyme-linked immunosorbent assay]) been completed?
Yes
No
Mitoxantrone
Member has ANY of the
following MS diagnosis:
Worsening relapsing-remitting to
reduce neurologic disability AND/OR
frequency of clinical relapse
Secondary (chronic)
progressive
Progressive
relapsing
Primary
progressive
Was cumulative lifetime dose exceeded?
Yes
No
The following labs have been completed within last SIX months:
☐
LVEF >50%
(not below lower limit of normal)
☐
ANC >1500 cells/mm3
☐
CBC
☐
LFTs
Effective: 03/03/2021 C4447-A 01-2021 Page 3 of 4
Proprietary
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.
Effective: 03/03/2021 C4447-A 01-
2021 Page 4 of 4
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 Multiple Sclerosis (MS) (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