Medical Exception Precertification Request Form
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Medical Exception/Precertification* Request
Fax to: 1-800-408-2386 or email:
https://
Form for Prescription Medications
Visit
to access the Pharmacy Clinical Policy Bulletins
Patient Name_____________________________________
Today’s Date____________________________________________
Patient Insurance ID #______________________________
Patient Date of Birth______________________________________
MD Office Phone (_____)__________________________
Physician Name (print)____________________________________
MD Office Fax (_____)_____________________________
Physician Signature (REQUIRED)___________________________
ANTIHISTAMINE
requested:
In order to process your request, ALL applicable fields MUST be completed
NP
NP
NP
NP
A
A
-D
C
C
-
LLEGRA
LLEGRA
LARINEX
LARINEX
D
NP
NP
NP
NP
fexofenadine (generic)
S
-D
Z
Z
-D
EMPREX
YRTEC
YRTEC
Diagnosis (
)
check all that apply
Allergic rhinitis
Chronic idiopathic urticaria
Asthma
Angioedema
Other: __________________________
Previous therapy, including OTCs ___________________________________
NONE
Dates
) ______________
(if available
Additional Information____________________________________________________________________________________
PROTON PUMP INHIBITOR
requested: In order to process your request, ALL applicable fields MUST be completed
P
P
P
NP
NP
NP
NP
P
A
omeprazole
N
P
P
Z
REVACID
CIPHEX
EXIUM
ROTONIX
RILOSEC
EGERID
Dosage requested ________ mg
QD
BID
TID
Other _______________________________________
Diagnosis (
)
check all that apply
GERD w/nocturnal acid breakthrough
GERD
Barrett’s esophagus
Hypersecretory condition
H. pylori
Laryngopharyngeal reflux
Other _______________________________________________________
Previous therapy, including OTCs ___________________________________
NONE Dates (
) ______________
if available
Additional Information____________________________________________________________________________________
ANTIFUNGAL
requested:
In order to process your request, ALL applicable fields MUST be completed
P
P
NP
NP
NP
NP
L
fluconazole (generic)
D
P
S
VFEND
AMISIL
IFLUCAN
ENLAC
PORANOX
Diagnosis (
)
check all that apply
Onychomycosis (*SEE BELOW*)
(Circle) Tinea capitis / pedis / cruris / corporis
Vulvovaginal candidiasis
Oral candida (thrush)
Other _______________________________________________________________________
Previous therapy, including OTCs ____________________________________
NONE
Dates (
) _____________
if available
Additional Information____________________________________________________________________________________
PLEASE COMPLETE FOR DIAGNOSIS: ONYCHOMYCOSIS
Fungal Lab Test Result:
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 __________________________________________________________________
For ALL other requests:
In order to process your request, ALL applicable fields MUST be completed
Drug requested:_________________________ Duration of therapy:_______________ Diagnosis: _______________________
Previous therapy, including OTCs __________________________________
NONE
Dates (
) _______________
if available
For Additional Quantities Drug:_____________________________ Strength(s): __________________________________
Provide the specific dosing schedule, including number of tablets per dose & number of doses per day:_____________________
_______________________________________________________________________________________________________
For Accutane/isotretinoin If female, pregnancy test results: ____________________ Test Date: _______________________
*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=Aetna Non-Preferred Drug
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