Express Scripts Prior Authorization Form - Topical Testosterone (Page 2 of 2) in pdf

 Yes

 No

 N/A

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

(endocrinologic masculinization)?

 Yes

 No

 N/A

7. Has the patient tried any of the following medications?

__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 upon each patient’s prescription plan, additional questions may be required to complete the prior authorization process. 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 F14

8.27.2013

Express Scripts Prior Authorization Form - Topical Testosterone Page 2