Fillable Pharmacy Prior Authorization Request Form Krystexxa (Mercy Care)

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Pharmacy Prior Authorization Request Form Krystexxa (Mercy Care)

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

  • 2 signatures
  • 7 check-boxes
  • 49 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
Krystexxa
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:
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
What medication(s) has member tried and failed for this diagnosis?
Please specify:
Medication request is NOT for an FDA- approved, or
c
ompendia-supp
orted diagnosis (circle one):
Yes No
Diagnosis: ICD-10 Code:
Are
there any contraindications to formulary medications?
Yes No
If yes
, please specify:
Directio
ns for U
se: Strength: Dosage Form:
Quantity:
Day Supply:
Duration of Therapy/Use:
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
Is the diagnosis CHRONIC GOUT refractory to conventional therapy?
Yes
No
Has the member experienced any
of the following in the past 18
months?
3 gout flares inadequately
controlled by colchicine or
NSAIDs
1 gout tophus or gouty arthritis
Was member screened and found to NOT
have G6PD Deficiency?
Yes
No
Will provider attest to monitoring during
and after infusion for possible anaphylaxis,
and infusion related reactions?
Yes
No
Documented 3 months trial and failure, or intolerance
with the following at maximum medically appropriate
doses, or member has contraindication to the agents:
Allopurinol or febuxostat
Probenecid (alone of in combination with allopurinol or febuxostat)
Will medication be used concomitantly with oral urate-lowering
Yes No
Effective: 06/28/20
21 C20656-A 01-2021 Page 1 of 2
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Page 2 of 2
therapies?
Renewal Requests ONLY
Has member had 2 consecutive uric acid
levels NOT ABOVE 6mg/dL since starting
treatment?
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: Incom
plete forms or forms without the chart notes will be returned
Office notes, labs, and medica
l 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.
Effec
tive: 06/28/2021 C20656-A 01-2021
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Pharmacy Prior Authorization Request Form Krystexxa (Mercy Care)

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Completed 31 July 2021

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