Fillable Pharmacy Prior Authorization Request Form Somatostatin Analogs & (Mercy Care)

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Pharmacy Prior Authorization Request Form Somatostatin Analogs & (Mercy Care)

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

  • 2 signatures
  • 39 check-boxes
  • 64 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
Somatostatin Analogs & Somavert
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 I
D: 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
☐
Octreotide
☐
Sandostatin Long Acting Release (LAR)
☐
Signifor
☐
Signifor LAR
☐
Somatuline Depot
☐
Somavert
Are there any contraindications to formulary medications? Yes No
If yes, please specify:
New
request
Continuation
of therapy
request
Medication request is NOT for an FDA approved, or
compendia-supported diagnosis (circle one):
Yes No
Diagnosis:
ICD-10 Code:
Directions for Use: Strength: Dosage Form:
Quantity:
Day Supply:
Duration of Therapy/Use:
What medication(s) has member tried and failed for this diagnosis?
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
Sandostatin LAR
Somatuline Depot
Baseline Testing: A1C or fasting glucose Thyroid-stimulating hormone Electrocardiography
Signifor
Signifor (LAR)
Baseline Testing: Potassium Magnesiu
m
Thyroid-Stimulating
Hormone
A1C or fasting plasma glucose
Liver Function Tests Gallbladder Ultrasound Electrocardiography
Somavert
Baseline Testing: LFTs are < 3x upper limit of normal
Additional Criteria Based on Indication
Effective: 06/28/2021 C5040-A, C4578-A 01-2021 Page 1 of 2
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signature
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Acromegaly
Member has
ONE of the
following:
Persistent disease following
radiotherapy AND/OR
pituitary surgery
Surgical resection is NOT an
option as evidenced by ONE
of the following:
Majority of tumor cannot be
resected
Member is a poor surgical
candidate based on comorbidities
Member prefers medical
treatment over surgery OR refuses
surgery
Baseline IGF-1
meets ONE of
the following:
≥2.5 times the upper limit of
normal for age
Remains elevated despite a 6-month trial of maximally tolerated dose of
cabergoline (unless member cannot tolerate, or has contraindication to
cabergoline
Carcinoid Tumor or Vasoactive Intestinal Polypeptide Secreting Tumor (VIPomas)
Cushing’s Syndrome
Has member had persistent disease after
pituitary surgery OR surgery is NOT an
option?
Yes No Did member have inadequate response,
intolerable side effects OR contraindication
to cabergoline?
Yes No
Hepato-Renal Syndrome
Will Octreotide be used in combination with midodrine and albumin?
Yes
No
Gastro-entero-pancreatic neuroendocrine tumor
Has member had persistent disease after surgical resection OR is NOT a candidate for surgery? Yes No
Renewal Requests ONLY
Response to
therapy for ALL
includes:
A1C or fasting
glucose
TSH
Electrocardiography
Monitor for cholelithiasis AND D/C if
complications of cholelithiasis
suspected
Acromegaly
Decreased or normalized IGF-1 levels
Yes
No
Cushing’s Syndrome
Decreased or normalized cortisol levels Yes No
Signifor
Liver Function Tests Yes No
Somavert
Liver Function Tests
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 o
r 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.
Effec
tive: 06/28/2021 C5040-A, C4578-A 01-2021 Page 2 of 2
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Pharmacy Prior Authorization Request Form Somatostatin Analogs & (Mercy Care)

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Completed 31 July 2021

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