Fillable Concomitant Antidepressant Treatment Pharmacy Prior Authorization Request Form (Mercy Care)

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Concomitant Antidepressant Treatment Pharmacy Prior Authorization Request Form (Mercy Care)

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

  • 2 signatures
  • 45 check-boxes
  • 33 other fields

Country of origin: US
File type: PDF

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Effective: 07/04/2019 C3242-A Page 1 of 2
Proprietary
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
Concomitant Antidepressant Treatment
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:
Pres
cribing 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:
Turn-Around Time
Standard – (24 hours) Urgent – Waiting 24 hours for standard decision could seriously harm life, health, or ability to regain
maximum function; you are requesting an expedited decision.
Signature:
___________________________________________________________
Requested Medication Information
SSRIs SNRIs Atomoxetine TCAs
Are there any contraindications to formulary medications? Yes
(If yes, please specify):
No New
request
Continuation
of therapy
Medications were started during recent hospitalization (circle one):
Yes No
Medication request is NOT for an FDA approved, or compendia-
supported diagnosis (circle one):
Yes No
What is the diagnosis ICD-10 Code? D
iagnosis:
What medication(s) were tried and failed for this diagnosis?
Directions for Use:
Quantity: Day Supply: Duration of Therapy/Use: Strength: Dosage Form:
Clinical Information
Is the cross-tapering due to transitioning from one medi
cation to another over a course of 60 days? Yes No N/A
Is there evidence of adequate trials with 3 individual antidepressants listed on the AHCCCS
Behavioral Health Drug List, from 2 different therapeutic classes?
Yes No
Were these trials for a period of 4-6 weeks at the maximum tolerated doses? Yes No
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Page 2 of 2
___________________________________________________ __________________
Failures were due to ONE of the
following:
Inadequate response at maximum
tolerated doses
Adverse reaction(s) Break through
symptoms
Are there TWO different prescribers prescribing that the coordination of care has occurred?
Yes No
Is there documentation that adherence to treatment regimen was not a contributing factor to
inadequate response to medication trials?
Yes No
Is there documentation that clinical
monitoring to the following were completed?
(check that apply)
target
symptoms
adverse
reactions
signs/symptoms of
serotonin syndrome
adherence to
treatment
blood pressure weight suicide risk heart rate
Is there documentation that clinical monitoring was completed for TCAs, which includes TCA levels,
and/or an ECG at baseline and then at follow up?
Yes No N/A
Is there a known hypersensitivity to the
requested agent(s)?
Yes No Is member currently taking an MAOI
medication?
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
Effect
ive: 07/04/2019 C3242-A
Proprietary
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Concomitant Antidepressant Treatment Pharmacy Prior Authorization Request Form (Mercy Care)

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Completed 31 July 2021

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