Aetna Ppi Exception Request Form Page 2

ADVERTISEMENT

Request Brand Name PPI other than generic PPI (e.g. omeprazole, pantoprazole )?
Yes
No. If yes, the following must be met.
Intolerance or contraindication to ALL generic PPI medications OR
Failure of an adequate trial of two weeks of the nonprescription omeprazole (Prilosec) OTC 20mg AND
Failure of an adequate trial of two weeks generic omeprazole 40 mg daily AND two weeks of generic
pantoprazole
 Yes  No.
Request for additional quantities or BID Dosing?
If yes, must have one of the following:
Member has a diagnosis of a pathological hypersecretory condition OR
Member is being treated for Barrett's esophagus OR
Member is being treated for laryngopharyngeal reflux OR
Member is Post transplant and/or MD is a transplant specialist OR
Member is being treated for a GI bleed (3-month duration) OR
Member is being treated for eradication of H. pylori (triple therapy only; 30-day duration) OR
Member has gastroesophageal reflux disease (GERD) and meets ALL the following criteria:
a. Member has had at least 4 wks of once daily PPI therapy taken 30-60 min before a meal (any meal)
b. Member is experiencing acid breakthrough OR
If Member is <11 years of age and has gastroesophageal reflux disease (GERD) or erosive esophagitis
and meets ALL the following criteria ( for Prevacid, omeprazole and Prilosec):
a. Member has had at least 4 wks of once daily PPI therapy taken 30-60 min before a meal (any meal)
b. Member is experiencing acid breakthrough
Proton Pump Inhibitor requested:
NP
NP
P
Generic pantoprazole (PROTONIX)
Generic omeprazole
PRILOSEC
PROTONIX
PREVACID
P
NP
NP
NEXIUM
ACIPHEX
ZEGERID
Other: ____________________________
 Other _________________ ______________________
Dosage requested ____________ mg
QD
BID
Duration of treatment?
_________ Months.
For Office Use Only:
Medical Necessity Review:
Medical Indication for Generic or Brand-Name Exception?
Yes
No.
Indication for additional quantities or BID dosing?
Yes
No.
MD Recommendation
Approve exception to allow generic prescription omeprazole or generic pantoprazole
Approve use of brand name PPI over generic or OTC PPI ___________________________________
Approve exception for additional quantities of brand name or generic PPI
Request for exception is denied for lack of medical necessity.
Other _______________________________________________________
______________________________________
______/_______/______
Medical Director
Date
Revised: April 13, 2010

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Form Gr-67834-20 - Aetna Enrollment Change Request Form Form Gr-67834-20 - Aetna Enrollment Change Request Form Business
Form Rpd - 41350 - E-file Exception Request Form Instructions - Taxation And Revenue Department Form Rpd - 41350 - E-file Exception Request Form Instructions - Taxation And Revenue Department Financial
Form Frx004 - Formulary Exception Request Form Form Frx004 - Formulary Exception Request Form Business
Form Frx002 - Expedited Formulary Exception Request Form Form Frx002 - Expedited Formulary Exception Request Form Business
Form Frx001 - Tier Exception Request Form Form Frx001 - Tier Exception Request Form Business
Form Rpd - 41350 - E-file Exception Request Form Form Rpd - 41350 - E-file Exception Request Form Financial
Molina Healthcare Of Florida Medication Prior Authorization / Exceptions Request Form Molina Healthcare Of Florida Medication Prior Authorization / Exceptions Request Form Medical
Geographic Exception Request Form Chp 13-1 Geographic Exception Request Form Chp 13-1 Legal
Rpd-41350 9/4/12 - E-file Exception Request Form - State Of New Mexico - Taxation And Revenue Department Rpd-41350 9/4/12 - E-file Exception Request Form - State Of New Mexico - Taxation And Revenue Department Financial
Cdphp Prior Authorization/medical Exception Request Form Cdphp Prior Authorization/medical Exception Request Form Business

Related Categories

Parent category: Business
Download
Go
Page of 2