Fillable Pyrimethamine (Daraprim) Pharmacy Prior Authorization Request Form (Mercy Care)

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Pyrimethamine (Daraprim) Pharmacy Prior Authorization Request Form (Mercy Care)

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

  • 2 signatures
  • 7 check-boxes
  • 67 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
Pyrimethamine (Daraprim)
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 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
Medication request is NOT for an FDA- approved, or
compendia-supported diagnosis (circle one): Yes No
Diagnosis:
ICD-10 Code:
Are there any c ontraindications to formulary medications?
Yes
No
If yes, please specify:
New
request
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 f or a standard decision could seriously harm life, health,
or ability to regain maximum f unction, you can ask f or an expedited decision.
Signature:
_____________________________________________________
Clinical Information
Will pyrimethamine be used in combination with
a sulfonamide AND leucovorin?
Yes
No
Will pyrimethamine be used in combination
with leucovorin ONLY?
Yes
No
Toxoplasmosis Encephalitis – Primary Prophylaxis
Does member have HIV with CD4 count < 100
cells/microL?
Yes
No
Is member seropositive for anti-toxoplasma
IgG?
Yes
No
Does member have intolerance or contraindication to trimethoprim-sulfamethoxazole? (for non-life-threatening
reactions, the national AIDS guideline recommends re-challenge)
Yes
No
Renewal ONLY
Was member complaint to treatment AND lab results support CD4 count?
Yes
No
Toxoplasmosis Encephalitis – Treatment, HIV Associated
Does member have HIV with CD4 count < 100
cells/microL?
Yes
No
Is member seropositive for anti-toxoplasma
IgG?
Yes
No
Do MRI or CT results support CNS lesions?
Yes
No
Toxoplasmosis Encephalitis - Chronic Maintenance Therapy (Secondary Treatment / Secondary Prophylaxis)
Has member successfully completed 6 weeks
of initial therapy?
Yes
No
Is there documented improvement in
clinical symptoms?
Yes
No
Effective: 08/18/2020 C8363-A 04-2020 Page 1 of 2
Proprietary
click to sign
signature
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Page 2 of 2
Does MRI or CT indicate improvement in ring
enhancing lesions, prior to start of maintenance
therapy?
Yes
No
Has Antiretroviral Therapy been initiated?
Yes
No
Acquired and Congenital Toxoplasmosis - Treatment (Non-HIV Related)
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.
E
ffective: 08/18/2020 C8363-A 04-2020
Proprietary
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Pyrimethamine (Daraprim) Pharmacy Prior Authorization Request Form (Mercy Care)

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Completed 31 July 2021

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