Aetna Medical Exception / Precertification Request Form

Medical Exception / Precertification* Request Form

For Prescription Medications

Fax to: 1-800-408-2386, call: 1-800-414-2386, or email: https://

Visit to access the Pharmacy Coverage Policy Bulletins

.

In order for us to process your request, ALL applicable fields MUST be filled in.

Patient Name

Today’s Date

Patient Insurance ID #

Patient Date of Birth

Physician Name (print)

Telephone (

)

Physician Signature

Fax (

)

(

)

REQUIRED

NF

NF

NF

NF

NF

NF

Please circle Antihistamine

requested: A

A

-D

C

S

-D

Z

Z

-D

LLEGRA

LLEGRA

LARINEX

EMPREX

YRTEC

YRTEC

Diagnosis

Allergic Rhinitis

Chronic Idiopathic Urticaria

Other ____________________________

(circle all that apply)

Previous therapy, including OTCs: ___________________________________________________Dates (if available) _______________________

Response to previous therapy

Inadequate response

Adverse effect(s) Comments _________________________________

(circle all that apply)

F

NF

F

NF

NF

NF

Please circle Proton Pump Inhibitor

requested: A

N

P

P

P

omeprazole (generic)

CIPHEX

EXIUM

REVACID

RILOSEC

ROTONIX

Dosage requested ________mg

QD

BID

TID

Other __________________________________________________

Diagnosis

GERD

Nocturnal acid breakthrough

Barrett’s esophagus

Hypersecretory condition

(circle all that apply

H. pylori eradication

Other __________________________________________________________

Previous therapy, with dates: _______________________________________________________________________________________________

_____________

Response to previous therapy

Inadequate response

Adverse effect(s) Comments ___________________

(circle all that apply)

NF

NF

Please circle COX-II Selective Inhibitor

requested: B

C

Dosage requested ________mg QD BID

EXTRA

ELEBREX

Diagnosis

Osteoarthritis

Rheumatoid Arthritis

Acute Pain

Primary Dysmenorrhea

(circle all that apply)

Familial Adenomatous Polyposis (FAP)

Other ___________________________________________

Previous therapy, with dates: _______________________________________________________________________________________________

Response to previous therapy

Inadequate response

Adverse effect(s) Comments __________________________________

(circle all that apply)

Patient history of Peptic ulcer or NSAID-related ulcer/GI bleed?

Yes

No

Patient using anticoagulants, antiplatelets, or corticosteroids?

Yes

No

Antifungal

Please circle

r

F

F

F

NF

NF

equested:

D

fluconazole (generic)

L

P

S

IFLUCAN

AMISIL

ENLAC

PORANOX

Diagnosis

Onychomycosis

Tinea capitis, pedis, cruris, corporis

Vulvovaginal Candidiasis

(circle all that apply)

Oral Candida (thrush)

Candida (esophageal, intestinal, UTI, other)

Other ________________________________

Previous therapy, with dates: _______________________________________________________________________________________________

Response to previous therapy

Inadequate response

Adverse effect(s) Comments __________________________________

(circle all that apply)

--------------------------------------------------------------------------------------------------------------------------------------------------

FOR ONYCHOMYCOSIS:

KOH, PAS, fungal culture results: _______

Test Date:__________

Location: Fingernail(s) Toenail(s)

Other existing conditions

)

Pain Limiting Activity

Diabetes Mellitus

Systemic dermatosis

(circle all that apply

Immunosuppression (AIDS, cancer, etc.)

Peripheral vascular disease

Other ______________________________________

If prior onychomycosis therapy, please note: Drug: ________________

Start Date: ___________

Duration: _______________________

Response to previous therapy

Inadequate response

Adverse effect(s) Comments: _________________________________

(circle all that apply)

NF

NF

NF

NF

F

Please circle Antilipidemic

requested:

A

C

C

L

lovastatin (generic)

LTOCOR

ADUET

RESTOR

IPITOR

NF

NF

NF

NF

NF

Formulary drugs = Lescol, Lescol XL, Zocor

M

P

P

V

Z

EVACOR

RAVACHOL

RAVIGARD

YTORIN

ETIA

Dosage requested ____________mg

Current LDL:_____________________

Target LDL: __________________________________

Current drug therapy with dose ________________________________________________ or NONE

(circle if applicable)

Previous therapies received (please include duration and note if inadequate therapeutic response, adverse effects, or contraindicated in patient):

_______________________________________________________________________________________________________________________

For ALL other precertification/medical exception requests

Drug requested: _____________________ Duration of therapy: ______________ Diagnosis: _________________________________________

Previous therapies received (please include duration and note if inadequate therapeutic response, adverse effects, or contraindicated in patient):

_______________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________

Accutane/isotretinoin

For

:

If female, pregnancy test results: ____________________

Test Date: ________________________________

*The term precertification means the utilization review process to determine whether the requested service, procedure, prescription drug or medical device meets the company’s

clinical criteria for coverage. It does not mean precertification as defined by Texas law, as a reliable representation of payment of care or services to fully insured HMO and

PPO member.

F=Formulary Drug;

NF=Non-Formulary Drug