Express Scripts Prior Authorization Request For Md Pmp Details

This general guide will let you establish just how long it'll require you to fill out express scripts androgel, how many pages it has, and some additional specific details about the PDF.

QuestionAnswer
Form NameExpress Scripts Androgel
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesexpress scripts prior authorization request for md pmp, express scripts prior authorization form testosterone, express scripts tier exception, express scripts prior authorization form medicare

Form Preview Example

Prior Authorization Form

Topical Testosterone

This form is based on Express Scripts standard criteria and may not be applicable to all patients; certain plans and situations may require additional information beyond what is specifically requested.

Additional forms available: www.express-scripts.com/pa

Fax completed form to 1-800-357-9577

If this an URGENT request, please call 1-800-417-8164

Patient Information

Patient First Name: ______________________________

Patient Last Name: _______________________________

Patient ID#: _____________________________________

Patient DOB: ____________________________________

Patient Phone #: _________________________________

Prescriber Information

Prescriber Name: __________________________________

Prescriber DEA/NPI (required): _______________________

Prescriber Phone #: ________________________________

Prescriber Fax #: __________________________________

Prescriber Address: ________________________________

State: ________________ Zip Code: __________________

Primary Diagnosis: _________________________________ ICD Code: ________________________________________

Please indicate which drug and strength is being requested:

Androderm 2.5mg/24hr Transdermal System

Androderm 5mg/24hr Transdermal System

Androgel 1% Metered Dose Pump Transdermal Gel

Androgel 1.62% Metered Dose Pump Transdermal Gel

Androgel 1% Transdermal Gel

Axiron 30mg/actuation Topical Solution

First-Testosterone 2% Compounding Kit

First-Testosterone MC 2% Compounding Kit

Fortesta 10mg/actuation Transdermal Gel

Striant 30mg Buccal System

Testim 1% Topical Gel

Other: ______________________________________________

Directions for use (i.e. QD, BID, PRN & Qty):__________________________________________________________________________

Please complete the clinical assessment:

1.

Does the patient have hypogonadism (primary or secondary) as confirmed by a low for

YES

NO

N/A

 

age pre-treatment serum testosterone (total or free) level defined by the normal

 

 

 

 

laboratory reference values?

 

 

 

 

 

 

 

 

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

YES

NO

N/A

 

endocrinologist?

 

 

 

 

 

 

 

 

4.

Does the patient have carcinoma of the breast OR known or suspected carcinoma of

YES

NO

N/A

 

the prostate?

 

 

 

 

 

 

 

 

5.

Is the patient 14 years of age or older AND the medication is being requested for the

YES

NO

N/A

 

treatment of delayed puberty or induction of puberty?

 

 

 

 

 

 

 

 

Topical Testosterone

8.27.2013

6.

Is the requested medication being used for female-to-male (FTM) gender reassignment

YES

NO

N/A

 

(endocrinologic masculinization)?

 

 

 

 

 

 

 

 

7.

Has the patient tried any of the following medications?

YES

NO

N/A

 

__Androderm

__Striant

 

 

 

 

__AndroGel

__Testim

 

 

 

 

__Axiron

__First-Testosterone MC

 

 

 

 

__Fortesta

__First-Testosterone

 

 

 

Are there any other comments, diagnoses, symptoms, and/or any other information the physician feels is important to this review?

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

Prescriber Signature: __________________________________________Date: ____________________

Office Contact Name: ___________________________ Phone Number: __________________________

Based upo ea h patie t’s p es iptio pla , additio al uestio s ay e e ui ed to o plete the p io autho izatio p o ess. If you have any questions about the process or required information, please contact our prior authorization team at the number listed on the top of this form.

Prior Authorization of Benefits is not the practice of medicine or a substitute for the independent medical judgment of a treating physician. Only a treating physician can determine what medications are appropriate for the patient. Please refer to the applicable plan for the detailed information regarding benefits, conditions, limitations, and exclusions.

The document(s) accompanying this transmission may contain confidential health information. This information is intended only for the use of the individual or entity named above. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or action taken in reliance on the contents of these documents is strictly prohibited. If you received this information in error, please notify the sender immediately and arrange for the return or destruction of the documents.

Topical Testosterone

8.27.2013

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