Fillable Pharmacy Prior Authorization Request Form Xolair (Mercy Care)

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Pharmacy Prior Authorization Request Form Xolair (Mercy Care)

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

  • 2 signatures
  • 13 check-boxes
  • 61 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
Xolair
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
What medication(s) has member tried and failed for this diagnosis?
Please specify:
Medication request is NOT for an FDA- approved, or
compendia-supported diagnosis (circle one):
Yes No
Diagnosis: ICD-10 Code:
Are there any contraindications to formulary medications?
Yes No
If y
es, please specify:
Direct
ions for Us
e: 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
Moderate to Severe Persistent Asthma
Does member have a positive skin test OR in-
vitro reactivity to perennial allergen (dust mite,
animal dander, cockroach, etc.)?
Yes
No
Is immunoglobulin E (IgE) between 30
and 1300 IU/mL?
Yes
No
Has member been compliant with medium to high dose ICS + LABA for 3 months OR other controller
medications (LTRA or theophylline), if intolerant to LABA?
Yes No
Asthma symptoms are poorly controlled
on 1 of above regimens as defined by ANY
of the following:
Daily use of
rescue
medications
Nighttime symptoms
occurring more than
once per week
At least 2 exacerbations in last 12
months requiring additional
medical treatment (systemic
corticosteroids, ER visits or
Effective: 06/28/2021 C7838-A 01-2021 Page 1 of 2
click to sign
signature
click to edit
Page 2 of 2
hospitalization)
Will member be receiving Nucala, Fasenra, Cinqair OR Dupixent?
Yes No
RENEWAL Reques
ts ONLY
Has member demonstrated clinical
improvement?
Yes
No
Was there decreased use of rescue
medications or systemic corticosteroids?
Yes
No
Was there a reduction in number of ER
visits or hospitalizations?
Yes
No
Was member compliant with asthma
controller medications?
Yes
No
Chronic Urticaria
Is member currently receiving H1
antihistamine therapy?
Yes No Was there fail
ure of a 4-week trial with high
dose cetirizine, loratadine or fexofenadine?
Yes No
There was failure of a 4-week trial of at least THREE
of the following combinations:
H1 antihistamine + Leukotriene inhibitor (montelukast or zafirlukast)
H1 antihistamine + H2 antihistamine (ranitidine or cimetidine)
H1 antihistamine + Doxepin
1
st
generation + 2
nd
generation antihistamine
RENEWAL Requests ONLY
Has member demonstrated adequate symptom control such as decreased itching? 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.
Effe
ctive: 06/28/
2021 C7838-A 01-2021
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Pharmacy Prior Authorization Request Form Xolair (Mercy Care)

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Completed 31 July 2021

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