Fillable Pharmacy Prior Authorization Request Form Sublocade (Mercy Care)

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Pharmacy Prior Authorization Request Form Sublocade (Mercy Care)

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

  • 2 signatures
  • 3 check-boxes
  • 69 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
Sublocade
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 to support diagnosis
Member Information
Member Name (first & last):
Date of Birth:
Gender:
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
Medication request is NOT for an FDA approved, or
compendia-supported diagnosis (circle one):
Yes No
Diagnosis:
ICD-10 Code:
Are there any contraindications to formulary medications?
Yes
No
If yes, please specify:
Continuation of
therapy request
Directions for Use:
Strength:
Dosage Form:
Quantity:
Day Supply:
Duration of Therapy/Use:
What medication(s) has the member tried and failed for this diagnosis? Please specify below.
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
Does member have severe Opioid Use
Disorder (OUD) as defined by DSM-5 OUD
Diagnostic Tool?
Yes
No
Does member have a demonstrated history
of non-adherence to oral medications?
Yes
No
Is member currently maintained on 8mg-24mg
per day dose of oral, sublingual OR
transmucosal buprenorphine product
equivalent for at least 7 days prior to start of
ER buprenorphine injection?
Yes
No
Will member receive supplemental, oral,
sublingual OR transmucosal
buprenorphine?
Yes
No
Is member receiving psychosocial interventions
as part of a comprehensive medication
assisted treatment (MAT) program?
Yes
No
Does prescriber meet DATA 2000
requirements AND has been assigned a
unique ID number specific to prescription of
medication assisted therapy (DEA-X)?
Yes
No
Has prescriber checked the Arizona State
Board of Pharmacy CSPMP database prior to
each monthly injection?
Yes
No
Is Sublocade dosing in accordance with
FDA approved labeling: 300mg SubQ
monthly for first 2 months, followed by
maintenance dose of 100mg or 300mg
monthly?
Yes
No
Renewal Requests ONLY
Is there documentation that member has
Yes
No
Has member OR will member receive
Yes
No
Effective: 04/14/2020 C14565-A 03-2020
Proprietary
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signature
click to edit
Page 2 of 2
experienced a positive clinical response to
buprenorphine ER therapy, as defined by
provider?
supplemental, oral, sublingual OR
transmucosal buprenorphine?
Is member receiving psychosocial interventions
as part of a comprehensive medication
assisted treatment (MAT) program?
Yes
No
Does prescriber meet DATA 2000
requirements AND has been assigned a
unique ID number specific to prescription of
medication assisted therapy (DEA-X)?
Yes
No
Has prescriber checked the Arizona State
Board of Pharmacy CSPMP database prior to
each monthly injection?
Yes
No
Is Sublocade dosing in accordance with
FDA approved labeling: 300mg SubQ
monthly for first 2 months, followed by
maintenance dose of 100mg or 300mg
monthly?
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
Stand
ard turnaround time is 24 hours. You can call 800-624-3879 to check the status of a request.
Effective: 04/14/2020 C14565-A
03-2020
Proprietary
click to sign
signature
click to edit
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Pharmacy Prior Authorization Request Form Sublocade (Mercy Care)

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Completed 31 July 2021

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