Medical Exception Precertification Request Form Page 2
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Medical Exception/Precertification* Request
Fax to: 1-800-408-2386 or email:
https://
Form for Prescription Medications
Visit
to access the Pharmacy Clinical Policy Bulletins
Patient Name:____________________________________
Today’s Date:___________________________________________
Patient Insurance ID #:_____________________________
Patient Date of Birth:_____________________________________
MD Office Phone (_____): _________________________
Physician Name (print): ___________________________________
MD Office Fax (_____):____________________________
Physician Signature (REQUIRED):__________________________
HMG Co-A
requested
In order for us to process your request, ALL applicable fields MUST be completed
:
P
P
P
P
P
NP
Z
V
/
lovastatin (
)
A
L
GENERIC
OCOR
YTORIN
LESCOL
LESCOL XL
DVICOR
IPITOR
NP
NP
NP
NP
NP
NP
P
M
A
C
C
RAVACHOL
PRAVIGARD
EVACOR
LTOPREV
RESTOR
ADUET
Diagnosis (
):
check all that apply
Hypercholesterolemia
Mixed lipidemia
Hyperlipidemia
Other: __________________________
Previous HMG therapy: _____________________________________________ Strength: ____________________
NONE
Dates (
): _______________________________________________________________________________________
if available
Additional Information:____________________________________________________________________________________
CNS STIMULANT
In order for us to process your request, ALL applicable fields MUST be completed
requested:
P
P
NP
NP
NP
NP
A
XR
M
CD/ER
C
S
P
R
LA/SR
DDERALL
ETADATE
ONCERTA
TRATTERA
ROVIGIL
ITALIN
Diagnosis (
):
check all that apply
ADD
ADHD
Narcolepsy
MS fatigue
Idiopathic hypersomnia
OSA (Obstructive Sleep Apnea)
Other____________________________________________________________
Previous therapy: ________________________________________________________________________________
NONE
Dates
): ______________ Additional Information:____________________________________________________
(if available
ANTIDEPRESSANT
In order for us to process your request, ALL applicable fields MUST be completed
requested:
P
P
P
NP
NP
P
CR
E
XR
W
XL
C
E
AXIL
FFEXOR
ELLBUTRIN
YMBALTA
FFEXOR
NP
NP
NP
Z
L
P
W
OLOFT
EXAPRO
ROZAC
EEKLY
Diagnosis (
):
check all that apply
Major depressive disorder
Generalized anxiety disorder (GAD)
Social anxiety disorder (SAD)
Perimenopausal hot flashes
DIABETIC peripheral neuropathic pain
Other ______________________________
NONE
Previous therapies – Please check brand or generic:
Paxil CR
Paxil
Generic
Brand
Prozac
Generic
Brand
Zoloft
Wellbutrin SR
Generic
Brand
Celexa
Generic
Brand
Lexapro
Remeron
Generic
Brand
Desyrel
Generic
Brand
Wellbutrin XL
Luvox
Generic
Brand
Additional Information:____________________________________________________________________________________
For ALL other requests:
In order to process your request, ALL applicable fields MUST be completed
Drug requested:_________________________ Duration of therapy:_______________ Diagnosis: _______________________
Previous therapy, including OTCs __________________________________
NONE
Dates (
) _______________
if available
For Additional Quantities Drug:_____________________________ Strength(s): __________________________________
Provide the specific dosing schedule, including number of tablets per dose & number of doses per day:_____________________
_______________________________________________________________________________________________________
For Accutane/isotretinoin 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 members.
P=Aetna Preferred Drug;
NP=Aetna Non-Preferred Drug
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