Catamaran Prior Authorization - Healthyct
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3Catamaran Prior Authorization Department
Phone:
800-626-0072
Fax:
866-511-2202
Prescriber Information
Last Name
First Name
DEA / NPI
Specialty
Phone
Fax
-
-
-
-
Member Information
Last Name
First Name
Member ID Number
DOB
Medication Information:
Drug Name and Strength:
Quantity:
Diagnosis:
Dosing:
You must answer ALL of the following questions
For injectable medications that are being purchased and administered by the physician’s office, fax this
Is the medication being purchased by the member at a specialty or retail pharmacy?
Y N
If Yes: Proceed filling out the fax form and submit via fax to Catamaran Prior Authorization Dept.
If No: Proceed filling out the fax form and submit via fax to HealthyCT at (855) 817-5696 to obtain a
Prior Authorization through medical coverage.
Aveed and Testopel Prior Authorization
Initial Therapy
You must answer ALL of the following questions
1.
Does the member have one of the following contraindications or exclusions to the use of injectable
Y N
testosterone? Please Circle
• Carcinoma of the breast
• Known or suspected carcinoma of the prostate
2.
Is the patient male?
Y N
3.
Does the patient have a diagnosis of hypogonadism (primary or hypogonadotropic)?
Y N
Is the patient’s condition associated with symptoms?
4.
Y N
Has the patient’s serum testosterone (total or free) been tested in the morning on TWO separate
5.
Y N
occasions?
Do the patient’s testosterone levels based on the laboratory’s normal reference value range
6.
Y N
support a need for replacement therapy?
Please document:
Patient’s serum testosterone (1) with date: ________________________________________
Patient’s serum testosterone (2) with date: ________________________________________
Lab’s reference range: ________________________to_______________________________
Repeat Therapy
You must answer ALL of the following questions
Page 1 of 3
5/20/2014
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