Fillable Pharmacy Prior Authorization Request Form Tepezza (Mercy Care)

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Pharmacy Prior Authorization Request Form Tepezza (Mercy Care)

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

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  • 9 check-boxes
  • 56 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
Tepezza
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:
Male Female
Height:
Member ID:
City:
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
What medication(s) has member tried and failed for this diagnosis?
Please specify:
Medication request is NOT for an FDA- approved, or
compendia-supported diagnosis (circle one):
Yes No
Diagnosis: ICD-10 Code:
Are t
here any contraindications to formulary medications?
Yes No
If yes,
please specify:
Direction
s for Us
e: Strength: Dosage Form:
Quantity:
Day Supply:
Duration of Therapy/Use:
Turn-Around Time for Review
Standard – (24 hours
)
Urgent – w
aiting 24 hou
rs 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
Member has one of the following
diagnosis:
Moderate to severe Graves'
orbitopathy (ophthalmopathy)
Thyroid-associated ophthalmopathy
(thyroid eye disease (TED))
Was there T/F with glucocorticoids?
(cumulative dose <1000mg
methylprednisolone OR equivalent)
Yes No Are glucocorticoids C/I or cannot be
tolerated?
Yes No
Was member on a high dose (> 1000mg methylprednisolone OR equivalent) steroid therapy in the past 4
weeks?
Yes
No
Is there documentation of baseline testing for all of the
following:
Proptosis
Clinical Act
ivity Score of greater than or equal to 4
Diplopia
Graves’ ophthal
mopathy-specific quality-of-live (GO-QOL) questionnaire
Does member require immediate surgical
ophthalmological intervention?
Yes
No
Is there a plan for corrective
surgery/irradiation?
Yes
No
Effective: 06/28/2021 C20625-A 01-2021 (1) Page 1 of 2
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Is there documentation the member is: Euthyroid
Mildly hypo/hy
per-thyroid with free thyroxine (FT4)
Free triio
dothyronine (FT3) levels less than 50% above or below normal
limits
elevated Blood Glucose and
symptoms of hyperglycemia?
Yes
No
Will a female of reproductive potential be
using effective contraception prior to
starting therapy, during treatment, and for
6 months following last dose of Tepezza?
Yes
No
N/A
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: Inc
omplete 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.
Effective: 06/28/2021 C20625-A 01-2021 (1) Page 2 of 2
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Pharmacy Prior Authorization Request Form Tepezza (Mercy Care)

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Completed 31 July 2021

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