Aetna Ppi Exception Request Form
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Fax to: 206-701-1225
Attention – Seattle Medical Director
City of Seattle
Pharmacy Exception Request Form
For Proton Pump Inhibitors
Patient Name___________________________________
Today’s Date ______________________________________
Patient Insurance ID #________________ ____________
Patient Date of Birth _________________________________
MD Office Phone (___ __)________________________
Physician Name (print )_______________________________
MD Office Fax (___ __)__________________________
Physician Signature _________________________________
The City of Seattle has a self-insured plan, which offers a $20 monthly allowance for all Proton Pump Inhibitors (PPI’s),
regardless of brand name or generic. This allowance includes Over-the-Counter PPI’s, as long as the member has a
prescription from their physician.
If it is medically necessary for the member to have additional quantities of omeprazole or a brand name PPI – the exception
form should be completed below by their physician; and if approved, the member can receive the brand-name PPI requested at
a higher benefit (which matches the City’s RX benefit plan of 40% member share for brand name drugs).
The member must have tried the generic or OTC equivalent prior to receiving approval for this exception. There is insufficient
medical evidence of the superiority of one PPI over another (brand or generic) at the equivalent dosage.
Please fax completed form to: Aetna Inc, Attn: Seattle Medical Director, 206-701-1225
Current therapy
Omeprazole
_________ mg
QD
BID
Other ________________
Pantoprazole _________ mg
QD
BID
Other ________________
Other generic PPI: _____________________
________ mg
QD
BID
Other ________________
Brand PPI:
__________________________
________ mg
QD
BID
Other ________________
Current Diagnosis:
***Currently on Plavix (clopidogrel) desire switch to Pantoprazole (least effect on CYP metabolism)***
Peptic ulcer disease - Duodenal ulcer or Gastric ulcer- active ulcer OR maintenance of healed ulcer
Gastrojejunal ulcer - active; maintenance
NSAID-induced gastric ulcer – healing , risk reduction for recurrence
Barrett's esophagus
Crohn's disease
Erosive esophagitis - active, maintenance, healed
Reflux esophagitis -associated with GERD
Gastrointestinal bleed
GERD - moderate to severe with symptoms (treatment, maintenance, screening)
H. pylori, treatment (30 days)
Hypersecretory conditions, including Zollinger-Ellison Syndrome
Laryngopharyngeal reflux
Post transplant
Chronic oral (systemic) corticosteroid therapy (> 60 days)
Other: ________________________________________________________________
Revised: April 13, 2010
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