Fillable rior Au Egrifta Pharmacy P thorization Request Form (Mercy Care)

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rior Au Egrifta Pharmacy P thorization Request Form (Mercy Care)

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The rior Au Egrifta Pharmacy P thorization Request Form (Mercy Care) form is 2 pages long and contains:

  • 2 signatures
  • 2 check-boxes
  • 67 other fields

Country of origin: US
File type: PDF

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Page 1 of 2
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
Egrifta
Pharmacy P
rior Au
thorization 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
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
Medication request is NOT for 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, specify:
New
request
Continuation of
therapy ONLY:
Was there positive clinical response of HbA1c within normal range?
No
Was there positive clinical response of IGF-1 within normal range?
No
Was there a decrease in waist circumference?
No
Directions for Use:
Strength:
Dosage Form:
Quantity:
Day Supply:
Duration of Therapy/Use:
What medication(s) has the 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
Is MALE waist circumference
≥95cm at start of therapy?
Yes
No
N/A
Is FEMALE waist circumference
≥94cm at start of therapy?
Yes
No
N/A
Is member currently receiving anti-
retroviral therapy?
Yes
No
Was there a baseline evaluation within past 3 months
of HgB A1C AND IGF?
Yes
No
Will HgB A1C be monitored every
3-4 months?
Yes
No
Is member at risk for medical complications due to
excess abdominal fat?
Yes
No
Does member have active
malignancy?
Yes
No
Does member have disruption of hypothalamic-pituitary
gland axis OR head trauma?
Yes
No
Is member a woman of childbearing age who is NOT pregnant AND using appropriate contraception?
Yes
No
Additional information the prescribing provider feels is important to this review. Please specify below or submit medical records.
Effective: 06/08/2020 C6654-A 02-2020
Proprietary
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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 C6654-A 02-2020
Proprietary
________________________________ __________________
___________________________________________________ __________________
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rior Au Egrifta Pharmacy P thorization Request Form (Mercy Care)

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Completed 31 July 2021

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