Aetna Forms for Prior Authorization

  Male              Female

Do you want a drug specific prior authorization criteria form faxed to your office?       Yes       No (If yes, no further questions are required).

What condition is the drug being prescribed for? ICD code………………………………………………………………

Diagnosis…………………………………………………………………………………………………………………………………

Does the patient have a diagnosis of cancer?        Yes          No

STEP THERAPY may be required. Please list all medications the patient has tried specific to the diagnosis and specify below:

Therapeutic failure, including length of therapy for each drug: …………………………………

Drugs (s) contraindicated: …………………………………………………………………………………………

Adverse even (e.g., toxicity, allergy) for each drug: ……………………………………………………

Is the request for a patient with one or more chronic conditions (e.g., psychiatric condition, diabetes) who is stable on the current drug(s) and who might be at high risk for a significant adverse event with a medication change? If so, specify anticipated significant adverse event:

Does the patient require a specific dosage (e.g., suspension, solution, injection)? If so, please provide dosage form:

Antiemetic (5-HT3) Agents/Erectile Dysfunction Agents/Stimulants/Provigil, Nuvigil/Testosterones

**FOR ANY DRUG/CLASS NOT LISTED ON THE BACK PAGE, PLEASE ATTACH ADDITIONAL INFORMATION, BUT CANNOT EXCEED TWO PAGES**

PRESCRIPTION BENEFIT PLAN MAY REQUEST ADDITIONAL INFORMATION OR CLARIFICATION, IF NEEDED, TO EVALUATE REQUESTS

Does the patient require nitrate therapy on a regular OR on an intermittent basis, or is the patient currently taking another ED medication?                                                        Yes          No

If a diagnosis of erectile dysfunction, is it due to neurogenic etiology, vasculogenic etiology, psychogenic etiology or mixed etiology?                                                         Yes          No

Is it being used for symptomatic Benign Prostatic Hyperplasia (BPH)?      Yes          No

ANTIEMETIC (5-HT3) AGENTS:

Is the patient receiving moderate to highly emetogenic chemotherapy?  Monthly frequency

Is the patient receiving radiation therapy? Monthly frequency                   Yes          No

If the patient has a diagnosis of Hyperemesis Gravidarum, has the patient experienced an inadequate treatment response to two of the following medications?      Yes          No

Vitamin B6, doxylamine, promethazine (Phenergan), trimethobenzamide (Tigan) or metoclopramide (Reglan)?                                                                                   Yes          No

TOPICAL TESTOSTERONES REPLACEMENT (lab requirements):

For testosterone replacement therapy, has the member been confirmed by one of the following

Yes          No

1. Two total fasting serum testosterone levels (below the testing laboratory’s reference range of below 300ng/dl if reference ranges are not available) which were drawn in the morning between 7:00 a.m. and 10:00 a.m. on two different days, OR

2. 2. Persons with low normal total testosterone levels (above 300 ng/dL but below 400 ng/dL, two low free or bioavailable fasting serum testosterone levels (below the testing laboratory’s reference range or less than 225 picomoles per liter (pmol/L) (6 ng/dL) if reference ranges are not available) which were drawn in the morning between 7:00 a.m. and 10:00 a.m. on two different days

PROVIGIL/NUVIGIL:

If the patient has a diagnosis of Obstructive Sleep Apnea, is the patient currently using a continuous positive airway pressure (CPAP) machine or another device?      Yes          No

ADHD STIMULANT AND NON-STIMULANTS:

Is this a renewal of existing therapy?                                                                      Yes          No

IF THIS IS A REQUEST FOR THERAPY, PLEASE USE A SEPARATE FORM FOR EACH SERVICE! (e.g., one form for PT with all codes and clinical, one form for OT with all codes and clinical etc.)