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 Cov
erage Guidelines are available at www.mercycareaz.org/providers/completecare-
forproviders/pharmacy
Testosterone Agents
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: 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 Name:
Medication request is NOT for an FDA- approved, or
compendia-supported diagnosis (circle one): Yes No
ICD-10 Code: Diagnosis:
What medication(s) have been tried and failed for diagnosis?
Are there any contraindications to formulary medications? Yes No
If yes, please specify:
Directions for Use: Strength: Dosage Form:
Quantity: Day Supply: Duration of Therapy/Use:
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
Testosterone Replacement Therapy
Are there 2 pre-treatment serum total testosterone levels confirmed on 2 separate mornings with results
below the normal range (<264ng/dL or less than reference range for lab)?
Yes No N/A
Is there 1 pretreatment free or bioavailable testosterone level (less than reference range for lab)? Yes No N/A
Does member have a condition that may alter sex-hormone binding globulin (for example obesity,
diabetes mellitus, hypothyroidism, etc.)?
Yes No N/A
Are member’s initial testosterone concentrations at or near the lower limit of normal? Yes No N/A
Does member have ONE of
the following diagnosis?
Bilateral
Orchiectomy
Genetic disorder due to hypogonadism
(for example, Klinefelter syndrome)
Panhypopituitarism
Was diagnosis of hypogonadism made during or recovery from an acute illness, or when member was engaged
in short-term use of certain medications (for example opioids or glucocorticoids)?
Yes No
Does member have a diagnosis of Prostate Cancer OR Male Breast Cancer? Yes No
Provider will be monitoring the following periodically
(check all that apply):
Serum
testosterone
Prostate
specific antigen
Hemoglobin
& hematocrit
Liver functions
tests
Renewal Request ONLY
Is testosterone within normal male range? Yes No Is hematocrit < 54%? Yes No
Effective: 08/18/2020 C17315-A 05-2020 Page 1 of 2
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