Table 14

Helpful Information for Completion of Prior Authorization Forms

Patient Criteria
Include HF phenotype: HFrEF; HFpEF
Identify NYHA functional class
Include recent measurement of LVEF with source documentation if requested
Identify agent requested or additional testing required with indications supported by evidence and/or guideline statements where applicable; especially for testing requests, clinical judgment is an appropriate rationale
Address previous therapies used and rationale for switching or addition of treatment requested
Address known contraindications to use, adverse effects, and steps intended to minimize risk of drugs or procedures
Document when appropriate that delay or interruption in therapy may cause harm to the patient
Work with local pharmacy resources and pharmacy professionals to jointly address prior authorization requirements; do not hesitate to appeal decisions that are contrary to best patient care. Document all steps taken in the patient’s health record.

HF = heart failure; EF = ejection fraction; HFpEF = heart failure with preserved ejection fraction; HFrEF = heart failure with reduced ejection fraction; LVEF = left ventricular ejection fraction; NYHA = New York Heart Association.

  • Required information may vary depending on payer and state.