Express Scripts Prior Authorization Form - Topical Testosterone
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1
2Prior Authorization Form
Topical Testosterone
This form is based on Express Scripts standard criteria and may not be
Fax completed form to 1-877-329-3760
applicable to all patients; certain plans and situations may require
additional information beyond what is specifically requested.
If this an URGENT request, please call 1-800-753-2851
Additional forms available:
Patient Information
Prescriber Information
Patient First Name: ______________________________
Prescriber Name: __________________________________
Prescriber DEA/NPI (required): _______________________
Patient Last Name: _______________________________
Prescriber Phone #: ________________________________
Patient ID#: _____________________________________
Prescriber Fax #: __________________________________
Patient DOB: ____________________________________
Prescriber Address: ________________________________
Patient Phone #: _________________________________
State: ________________ Zip Code: __________________
Primary Diagnosis: _________________________________ ICD Code: ________________________________________
Please indicate which drug and strength is being requested:
□
□
Androderm 2.5mg/24hr Transdermal System
First-Testosterone 2% Compounding Kit
□
□
Androderm 5mg/24hr Transdermal System
First-Testosterone MC 2% Compounding Kit
□
□
Androgel 1% Metered Dose Pump Transdermal Gel
Fortesta 10mg/actuation Transdermal Gel
□
□
Androgel 1.62% Metered Dose Pump Transdermal Gel
Striant 30mg Buccal System
□
□
Androgel 1% Transdermal Gel
Testim 1% Topical Gel
□
□
Axiron 30mg/actuation Topical Solution
Other: ______________________________________________
Directions for use (i.e. QD, BID, PRN & Qty):__________________________________________________________________________
Please complete the clinical assessment:
Yes
No
N/A
1. Does the patient have hypogonadism (primary or secondary) as confirmed by a low for
age pre-treatment serum testosterone (total or free) level defined by the normal
laboratory reference values?
Yes
No
N/A
2. Is the requested medication going to be used to enhance athletic performance?
Yes
No
N/A
3. Is the requested medication being prescribed by, or in consultation with, an
endocrinologist?
Yes
No
N/A
4. Does the patient have carcinoma of the breast OR known or suspected carcinoma of
the prostate?
Yes
No
N/A
5. Is the patient 14 years of age or older AND the medication is being requested for the
treatment of delayed puberty or induction of puberty?
Topical Testosterone F14
8.27.2013
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