Fillable Spravato Nasal Spray Pharmacy Prior Authorization Request Form (Mercy Care)

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Spravato Nasal Spray Pharmacy Prior Authorization Request Form (Mercy Care)

On average this form takes 21 minutes to complete

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

  • 2 signatures
  • 11 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
Spravato Nasal Spray
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:
Male
Female
Height:
Member ID:
City:
State:
Weight:
Prescribing Provider Information
Provider Name (first & last):
Specialty:
NPI#
DEA#
Office Address:
City:
State:
Zip Code:
Office Phone
Office Fax:
Dispensing Pharmacy Information
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:
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 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 a confirmed diagnosis of major
depressive disorder as defined by the DSM-V
criteria and is treatment resistant?
Yes
No
Spravato is prescribed by or in consultation
with a psychiatric provider?
Yes
No
Member does not have an active substance
use disorder (SUD)?
Yes
No
Member has an active substance use
disorder and the member is currently
receiving therapy?
Yes
No
Has member experienced an inadequate response during the current
depressive episode with the following therapies? TWO
antidepressants from at least TWO different classes having different
mechanisms of action at the maximally tolerated labeled dose, each
used for at least 4 – 6 weeks? (check any that apply)
AHCCCS preferred SSRI
AHCCCS preferred SNRI
AHCCCS preferred buprenorphine
Has member experienced an inadequate response during the current
depressive episode with at least TWO augmentation therapies for at
least 4 weeks? (check any that apply)
SSRI or SNRI and a second-generation antipsychotic used
concomitantly (aripiprazole, quetiapine, risperidone,
olanzapine)
SSRI or SNRI and lithium used concomitantly
SSRI or SNRI and liothyronine (T3) used concomitantly
SSRI or SNRI and mirtazapine
Effective: 07/22/2020 C17690-A 06-2020 Page 1 of 2
Proprietary
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SSRI and bupropion and buspirone
Does member have active suicidal ideation and
urgent symptom control is necessary?
Yes
No
Will Esketamine be used in combination
with an oral antidepressant (e.g.,
duloxetine, escitalopram, sertraline,
venlafaxine)?
Yes
No
Esketamine is administered under the direct
supervision of a healthcare provider?
Yes
No
Provider is certified in the Spravato REMS
program?
Yes
No
Will member be monitored by a health care provider for at least 2 hours after administration?
Yes
No
Renewal ONLY
Provider attests that the member has documented improvement or sustained improvement in depressive symptoms
from baseline?
Yes
No
Member use of esketamine is in combination
with an oral antidepressant?
Yes
No
Member administers esketamine under the
direct supervision of a healthcare provider?
Yes
No
Provider is certified in the Spravato REMS
Program?
Yes
No
Member will be monitored by a health care
provider certified by the Spravato REMS
Program for at least 2 hours after
administration?
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.
Standard turnaround time is 24 hours. You can call 800-624-3879 to check the status of a request.
Effective: 07/22/2020 C17690-A 06-
2020
Proprietary
Page 2 of 2
________________________________
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Spravato Nasal Spray Pharmacy Prior Authorization Request Form (Mercy Care)

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Completed 31 July 2021

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