Fillable Spinraza Pharmacy Prior Authorization Request Form (Mercy Care)

Fill Online, Printable, Fillable, Blank Spinraza Pharmacy Prior Authorization Request Form (Mercy Care) Form

Use Fill to complete blank online MERCY CARE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Spinraza Pharmacy Prior Authorization Request Form (Mercy Care)

On average this form takes 16 minutes to complete

The Spinraza 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

Use our library of forms to quickly fill and sign your Mercy Care forms online.

BROWSE MERCY CARE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐ ☐
☐
☐
☐
☐
☐
☐
☐
☐
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. Inc
omplete forms or forms without the chart notes will be
returned
Pharmacy Coverage Guidelines are available at ww
w.mercycareaz.org/providers/completecare-
forproviders/pharmacy
Spinraza
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:
Prescribing Provider Information
Provider Name (first & last):
Specialty:
NPI#
DEA#
Office Address:
City:
State:
Zip Code:
Office Contact:
Office Phone
Dispensing Pharmacy Information
Pharmacy Name:
Pharmacy Phone:
Requested Medication Information
Are there any contraindications to formulary medications?
Yes
No
New request Continuation of therapy
(If yes, please specify):
Medication request is NOT for an FDA-approved, or
compendia-supported diagnosis (circle one):
Yes No
What medication(s) have been tried and failed for this diagnosis? (Please
specify):
What is the diagnosis ICD-10 Code?
Diagnosis:
Directions for Use:
Strength:
Quantity:
Day Supply:
Turn-Around Time for Review
Standard – (24 hours) Urgent – If w aiting 24 hours for standard decision could seriously harm life, health, or ability to regain
maximum function, y ou can ask for an expedited decision.
Signature: _______________________________________
_______________________________
Clinical Information – Initial Request
Was diagnosis confirmed by genetic
testing?
Yes
No
Was documentation presented showing member has
Type I, Type II, or Type III Spinal Muscular Atrophy?
Yes
No
Is documentation presented showing member is confirmed to have at least 2 copies of Survival Motor Neuron-2 gene?
Yes
No
Genetic testing confirms presence of one of the
following chromosome 5q mutations or
deletions:
Homozygous
deletions of Survival
Motor Neuron-1 gene
Homozygous mutation in
Survival Motor Neuron-1 gene
Compound heterozygous
mutation in Survival Motor
Neuron-1 gene
Is member dependent on any of the following
(check one):
Invasive ventilation for more than 16 hours per day, or tracheostomy
Non-invasive ventilation for at least 12 hours per day
Was baseline motor milestone
score obtained using one of the
following assessments (check one):
Hammersmith
Functional Motor
Scale Expanded
Hammersmith
Infant Neurologic
Exam Part 2
Revised
Upper Limb
Module test
Children’s Hospital of
Philadelphia Infant Test of
Neuromuscular Disorders
Six-minute
walk test
Effective: 08/01/2019 C16377-A Page 1 of 2
Proprietary
click to sign
signature
click to edit
☐
☐
☐
☐
☐
☐
☐ ☐
☐ ☐
☐
☐ ☐
☐ ☐
☐ ☐
☐
☐
Were the following baseline labs presented to rule out
coagulation abnormalities and thrombocytopenia?
Platelet count
Prothrombin time (PT)
activated partial
thromboplastin time (aPTT)
Was a quantitative spot urine protein test completed at baseline to rule out renal toxicity presented?
Yes
No
Clinical Information – Renewal
ALL the following laboratory tests were
completed showing improvement from
pretreatment baseline status?
Platelet count Prothrombin
time
Activated partial
thromboplastin time
Quantitative spot urine
protein test
A response to therapy was demonstrated
by one of the following:
Maintained or improved motor
milestone score using same exam as
performed at baseline
Achieved and maintained any new motor milestones,
when otherwise would be unexpected to do so, using
same exam as performed at baseline
Exams (check that apply)
Hammersmith Infant Neurologic Exam
Part 2
There was an improvement, or
maintenance of previous
improvement, of at least a 2-point
increase in ability to kick
There was an improvement, or maintenance of
previous improvement, of at least a 1-point increase, in
any other milestone (for example, head control, rolling,
sitting, crawling), excluding voluntary grasp
Hammersmith Functional Motor Scale
Expanded
There was an improvement, or maintenance of previous improvement, of at least a 3-point
increase in score from baseline
Revised Upper Limb Module
There was an improvement, or maintenance of previous improvement, of at least a 2-point
increase in score from baseline
Children’s Hospital of Philadelphia
Infant Test of Neuromuscular Disorders
There was an Improvement, or maintenance of previous improvement, of at least a 4-point
increase in score from baseline
6-Minute Walk Test
Maintained, or improved score from baseline
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, l
abs, 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.
Eff
ective: 08/01/2019
C16377-A Page 2 of 2
Proprietary
___________________________________________________
__________________
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Spinraza Pharmacy Prior Authorization Request Form (Mercy Care)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 31 July 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document