Fillable Pharmacy Prior Authorization Request Form Injectable Osteoporosis Agents (Mercy Care)

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Pharmacy Prior Authorization Request Form Injectable Osteoporosis Agents (Mercy Care)

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The Pharmacy Prior Authorization Request Form Injectable Osteoporosis Agents (Mercy Care) form is 3 pages long and contains:

  • 2 signatures
  • 18 check-boxes
  • 145 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
Injectable Osteoporosis 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:
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
Preferred Agents:
Forteo
Prolia
Is request for a Non-Preferred agent?
Yes
No
Has the member had a trial and failure with ALL the
preferred agents?
Yes
No
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:
Initial
request
Continuation of
therapy request
If continuation of therapy, is there documentation to support member is benefiting from therapy (for example, improved
or stabilized BMD, no new fractures)?
Yes
No
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
Will member be supplemented with adequate
calcium and vitamin D ?
(exception: Forteo, teriparatide)
Yes
No
N/A
Is there a contraindication
to requested drug?
Yes
No
Prolia ONLY:
Is member pregnant?
Yes
No
Does member have hypocalcemia?
Yes
No
Zoledronic Acid ONLY:
Does member have
hypocalcemia?
Yes
No
Is members’ CrCl
<35mL/min?
Yes
No
Does member have
acute renal impairment?
Yes
No
Evenity ONLY:
Yes
No
Does member have hypocalcemia OR MI OR stroke within preceding year?
Yes
No
Additional Clinical Information
Is diagnosis of osteoporosis (T-score < -2.5 OR fragility fracture at hip, spine, wrist, arm, rib OR pelvis)?
Yes
No
Did member have failure with oral OR IV bisphosphonate despite compliance, including new fracture OR reduction in
BMD per recent DEXA scan, after TWO years of oral bisphosphonate?
Yes
No
Is there contraindication OR severe intolerance to oral bisphosphonate? (For example, current upper GI symptoms,
inability to swallow, inability to remain in upright position after oral bisphosphonate administration)?
Yes
No
Effective: 06/28/2021 01-2021 C18041-A, C18042-A, C18044-A, C18046-A, C18111-A Page 1 of 3
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signature
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Effective: 06/28/2021 01-2021 C18041-A, C18042-A, C18044-A, C18046-A, C18111-A Page 2 of 3
Request for males
Is testosterone level normal for lab reference range?
Yes
No
Is member hypogonadal?
Yes
No
N/A
Will testosterone replacement therapy be prescribed
before starting treatment?
Yes
No
Does member have history of
prostate cancer?
Yes
No
Prevention of Osteoporosis in Postmenopausal Women
Is diagnosis of osteopenia (T-score between -1.0
and -2.5) AND high risk for osteoporosis fracture?
Yes
No
Fracture Risk Assessment Tool risk ≥3.0%
for hip fracture OR ≥ 20% for any major
osteoporosis related fracture OR multiple
risk factors for fracture?
Yes
No
Was there failure of oral OR IV bisphosphonate
despite compliance, including new fracture OR
reduction in BMD per recent DEXA scan, after
TWO years of oral bisphosphonate?
Yes
No
Was there a contraindication OR severe
intolerance to oral bisphosphonate
(current upper GI symptoms, inability to
swallow OR inability to remain in upright
position after oral bisphosphonate
administration)?
Yes
No
Renewal Request ONLY
Does member have a stable BMD without
fractures?
Yes
No
Has BMD has worsened OR member had
fractures?
Yes
No
Glucocorticoid-Induced Osteoporosis
Is member a postmenopausal woman OR man
>50 years of age?
Yes
No
Has member received OR is expected to
receive, prednisone ≥7.5mg/day for > 3
months?
Yes
No
Is member premenopausal woman or man <50
years of age?
Yes
No
Does member have history of fragility
fracture AND received OR is expected to
receive, prednisone ≥7.5mg/day for >3
months?
Yes
No
Was there failure of oral OR IV bisphosphonate
despite compliance (including new fracture OR
reduction in BMD per recent DEXA scan, after
TWO years of oral bisphosphonate)?
Yes
No
Was there a contraindication OR severe
intolerance to oral bisphosphonate
(current upper GI symptoms, inability to
swallow OR inability to remain in upright
position, after oral bisphosphonate
administration)?
Yes
No
Renewal Request ONLY
While on treatment, does the member have stable
bone mineral density without fractures?
Yes
No
While on treatment, has bone mineral
density has worsened, or member had
fractures?
Yes
No
Bone Metastases of Cancer AND Multiple Myeloma
Does member have diagnosis of solid tumor with
bone metastases?
Yes
No
Does member have diagnosis of multiple
myeloma?
Yes
No
Does member have diagnosis of castration-resistant prostate cancer with bone metastases?
Yes
No
Increase of Bone Mass in MEN on Androgen Deprivation Therapy for Prostate Cancer WITHOUT Bone Metastases
Is member at high risk for osteoporosis fracture (FRAX risk ≥3.0% for hip fracture OR ≥20% for any major
osteoporosis related fracture OR multiple risk factors for fracture)?
Yes
No
Was there failure of oral OR IV bisphosphonate
despite compliance (including new fracture OR
reduction in BMD per recent DEXA scan, after
TWO years of oral bisphosphonate)?
Yes
No
Was there a contraindication OR severe
intolerance to oral bisphosphonate
(current upper GI symptoms, inability to
swallow OR inability to remain in upright
position, after oral bisphosphonate
administration)?
Yes
No
Increase of Bone Mass in WOMEN on Aromatase Inhibitory therapy for Breast Cancer WITHOUT Bone Metastases
Is member POST-menopausal OR PRE-menopausal with diagnosis of osteoporosis
(T-score < -2.5 OR fragility fracture at hip, spine, wrist, arm, rib OR pelvis)?
Yes
No
Was there failure of oral OR IV bisphosphonate
despite compliance (including new fracture OR
reduction in BMD per recent DEXA scan, after
TWO years of oral bisphosphonate)?
Yes
No
Was there a contraindication OR severe
intolerance to oral bisphosphonate
(current upper GI symptoms, inability to
swallow OR inability to remain in upright
position, after oral bisphosphonate
administration)?
Yes
No
Hypercalcemia of Malignancy
Does member have moderate OR severe
hypercalcemia associated with malignancy?
Yes
No
Is member receiving vigorous saline
hydration with goal of increasing urine
output to about 2 L/day?
Yes
No
Paget's Disease of Bone
Does member have bone specific alkaline phosphatase > 2 times ULN, OR symptoms related to active Paget’s (pain
at site of pagetic lesion)?
Yes
No
Is there normal serum calcium, phosphorus AND
Yes
No
If ABNORMAL serum calcium,
Yes
No
25-hydroxyvitamin D (based on reference range
for lab)?
phosphorus AND 25-hydroxyvitamin D,
will abnormalities be treated before
starting IV bisphosphonates?
Was there failure of oral OR IV bisphosphonate
despite compliance (including new fracture OR
reduction in BMD per recent DEXA scan, after
TWO years of oral bisphosphonate)?
Yes
No
Was there a contraindication OR severe
intolerance to oral bisphosphonate
(current upper GI symptoms, inability to
swallow OR inability to remain in upright
position, after oral bisphosphonate
administration)?
Yes
No
Renewal Request ONLY
Has bone specific alkaline phosphatase risen
after initial treatment?
Yes
No
Does member have symptoms?
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 t
o check the status of a request.
E
ffective: 06/28/2021 01-2021 C18041-A, C18042-A, C18044-A, C18046-A, C18111-A Page 3 of 3
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Pharmacy Prior Authorization Request Form Injectable Osteoporosis Agents (Mercy Care)

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Completed 31 July 2021

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