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Effective: 08/18/2020 C16523-A Page 1 of 2
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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
Pulmonary Arterial Hypertension Agents
Pharmacy Prior Authorization Request Form
Do not copy for future use. Forms are updated frequently
REQUIRED: Office notes, labs and med
ical 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: State: Weight:
Prescribing Provider Inf
ormation
Provider Name (first & last): Specialty: NPI# DEA#
Office Address: City: State: Zip Code:
Office Contact: Office Phone Office Fax:
Dispensing Pharmacy Information
Ph
armacy Name
: Pharmacy Phone: Pharmacy Fax:
Requested M
edication
Information
Preferred Agents:
Tracleer Tablets Letairis Adcirca Sildenafil Revatio suspension
Non-Preferred Agents:
Revatio tab Uptravi
Orenitram ER Opsumit Adempas
epoprostenol Veletri Remodulin
treprostinil
Tyvaso
Ventavis Other, please specify:
Are there any contraindications to formulary medications? Y
es No
If yes,
please specify:
New
request
Continuation of
therapy request
For continuation of therapy requests
ONLY:
Response to
t
herapy
Maintained OR achieved low risk profile (for example, improvement in 6
min walk distance, functional class, or reducing time to clinical worsening)
Directions for Use: Strength: Dosage Form:
Quantity: Day Supply: Duration of T
herapy/Use:
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 (c
ircle one):
Yes No
Diagnosis: ICD-10 Code:
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 - General Authorizatio
n Criteria
Was there evidence of right heart
catheterization wit
h mPAP ≥25mmHg?
Yes No Is diagnosis of Pulmonary Arterial
Hypertension WHO Group I with Functional
Class II to IV symptoms?
Yes No
Did member have inadequate response OR
intolerance to a CCB
?
Yes No Was there a contraindication to use of CCBs? Yes No
Did member have a negative vasoreactivity
test?
Yes No Was t
here a contraindication to vasoreactivity
test? (for example, low BP, low cardiac index,
OR presence of severe Functional Class IV
symptoms?
Yes No
Did member have a positive v
asoreactivity
test with inadequate response OR
intolerance to ONE CCB? (for example,
Yes No Will there be concurrent use of nitrate OR
nitric oxide donors such as isosorbide
mononitrate, isosorbide dinitrate OR
Yes No
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