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Medical Exception/Precertification*

Fax this form to: 1-800-408-2386 OR

Submit your request online at:

Request for Prescription Medications

Visit

to access

For FASTEST service, call 1-800-414-2386

our Pharmacy Clinical Policy Bulletins

Monday-Friday, 8 a.m. to 7 p.m. Central Time

Patient Name

Today’s Date

Patient Insurance ID Number:

Patient Date of Birth

M.D. Office Telephone Number

Physician Name (print)

M.D. Office Fax Number

Physician Signature (Required)

Office contact for questions or clarifications:

Office Contact Telephone Number (include extension)

NON-SEDATING ANTIHISTAMINE - To process your request, ALL fields MUST be completed

Please note: loratadine (CLARITIN/CLARITIN D) & cetirizine (ZYRTEC/ZYRTEC D) will not be covered - an over-the-counter (OTC) equivalent is available

CLARINEX

CLARINEX-D

SEMPREX-D

XYZAL

ALLEGRA

ALLEGRA-D/ALLEGRA-D 24 HOUR

fexofenadine

Dose Requested:

BID

Other

Additional information

Diagnosis (check all that apply):

Allergic rhinitis

Chronic idiopathic urticaria

Asthma

Angioedema

Other

List ALL previous oral therapies (including OTC’s):

None

Date(s) (if available)

____________________________________________________________________________________________

PROTON PUMP INHIBITOR - To process your request, ALL fields MUST be completed

Please note: On some plans omeprazole (PRILOSEC) 20 mg & Prevacid 15 mg will not be covered - over-the-counter (OTC) equivalents are available

KAPIDEX

NEXIUM

lansoprazole

omeprazole

pantoprazole

ZEGERID

ACIPHEX

PREVACID

PRILOSEC

PROTONIX

Dose Requested:

BID

Other

___________

Diagnosis (check all that apply):

GERD w/acid breakthrough (please complete additional 2 questions below)

How close to a meal was the dose given?

min.

Has member tried 4 wks of once daily PPI therapy?

Yes

GERD

H. pylori

GI bleed

Barrett’s esophagus

Hypersecretory condition

Laryngopharyngeal reflux

Ulcer (specify type)

______________

Other

Previous therapy (including OTCs):

None

Date(s) (if available)

Additional information

ORAL & TOPICAL ANTIFUNGAL – To process your request, ALL fields MUST be completed

NP*

terbinafine

fluconazole

itraconazole

ciclopirox soln

LAMISIL

DIFLUCAN

SPORANOX

PENLAC

*For fluconazole, provide strength, number of tablets per dose & number of doses per day:

______________________________

Diagnosis:

Onychomycosis

Complete this section ONLY for Diagnosis: ONYCHOMYCOSIS

Fungal lab test results:

Positive

Negative

Test date:

_______________

Location:

Fingernail(s)

Toenail(s)

Other existing conditions (check all that apply):

Pain-limiting activity

Diabetes mellitus

Systemic dermatosis

Immunosuppression (AIDS, cancer)

Peripheral vascular disease

Other

___________________________________________________________________

All Other Diagnosis (check all that apply):

Onychomycosis* (see above)

Tinea (circle): capitis / pedis / cruris / corporis

Other

Oral candida (thrush)

Vulvovaginal candidiasis (if recurrent, list dates in previous 12 months

Previous therapy (including OTCs):

None

Date(s) (if available)

Additional information

OTHER REQUESTS – To process your request, ALL fields MUST be completed

Drug Name

Duration of therapy

Diagnosis

Previous therapy (including OTCs):

None

Date(s) (if available)

For Additional quantities Drug

Strength

Provide the specific dosing schedule, including number of tablets per dose and number of doses per day

For isotretinoin products (All brands and generics) – Is the patient enrolled in the iPledge program?

*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= Non-preferred Drug

GR-68461 (08-2009)

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