Fillable r Authorization Entresto Pharmacy Prio Request Form www.mercycareaz.org/providers/completecare-forproviders/pharmacy (Mercy Care)

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r Authorization Entresto Pharmacy Prio Request Form www.mercycareaz.org/providers/completecare-forproviders/pharmacy (Mercy Care)

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The r Authorization Entresto Pharmacy Prio Request Form www.mercycareaz.org/providers/completecare-forproviders/pharmacy (Mercy Care) form is 2 pages long and contains:

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  • 4 check-boxes
  • 72 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
Entresto
Pharmacy Prio
r 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 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):
NPI#
DEA#
Office Address:
State:
Zip Code:
Office Contact:
Office Phone
Office Fax:
Dispensing Pharmacy Information
Pharmacy Name:
Pharmacy Phone:
Pharmacy Fax:
Requested Medication Information
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 yes, please specify:
New
request
Continuation of therapy
ONLY:
Was there response to treatment?
Yes
No
Was Entresto used with other HF therapies (BB, aldosterone antagonist OR
combination therapy with hydralazine AND isosorbide dinitrate)?
Yes
No
Is member a female AND of childbearing age?
Yes
No
Is member pregnant?
Yes
No
N/A
Was combination therapy with hydralazine AND isosorbide dinitrate used?
Yes
No
Directions for Use:
Strength:
Dosage Form:
Quantity:
Day Supply:
Duration of Therapy/Use:
What medication(s) has member tried and failed for this diagnosis? Please specify below.
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
Will medication be used concomitantly OR within 36
hours of last dose of ACEI OR medication
containing aliskiren (Tekturna OR Tekturna-HCTZ)?
Yes
No
Does member have severe hepatic
impairment (Child Pugh Class C) AND
history of angioedema?
Yes
No
Is member a female AND of childbearing age?
Yes
No
Is member pregnant?
Yes
No
Members Ages 18 Years OR Older
Does member have NYHA Class II-IV chronic HF with reduced ejection fraction ≤40%?
Yes
No
Is member tolerating an ARB OR an ACEI?
Yes
No
Will Entresto replace the ARB and/or
ACEI?
Yes
No
Will Entresto be used in conjunction with other HF therapies (beta blockers, aldosterone antagonist OR combination
therapy with hydralazine AND isosorbide dinitrate)?
Yes
No
Members Ages 1 Year OR Older
Does member have symptomatic HF and
systemic left ventricular systolic dysfunction?
Yes
No
Has member tried AND failed enalapril?
Yes
No
Additional information the prescribing provider feels is important to this review. Please specify below or submit medical records.
Effective: 06/08/2020 C9614-C 02-2020 Page 1 of 2
Proprietary
click to sign
signature
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Page 2 of 2
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.
E
ffec
tive: 06/08/2020 C9614-C 02-2020
Proprietary
__ ________________________________
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r Authorization Entresto Pharmacy Prio Request Form www.mercycareaz.orgproviderscompletecare-forproviderspharmacy (Mercy Care)

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Completed 31 July 2021

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