Aveed
Prior Authorization Request
CVS Caremark administers the specialty pharmacy benefit plan for the patient identified. This
patient’s benefit plan requires prior authorization for certain medications in order for the drug to be
covered. To make an appropriate determination, providing the most accurate diagnosis for the use
of the prescribed medication is necessary. Please respond below and fax this form to Assurant
Health at 414-299-7555. If you have questions regarding the prior authorization, please contact
Assurant Health Rx Srvcs @ 1800-800-1212 ext 6777.
Patient’s Name: _____________________________
Date: ________________________________
Patient’s ID: _______________________________
Patient’s Date of Birth: ________________
Physician’s Name: _______________________________________________________________________
Specialty: _________________________________
NPI#: ________________________________
Physician Office Telephone: __________________
Physician Office Fax: ___________________
Approvals may be subject to dosing limits in accordance with FDA-approved labeling,
accepted compendia, and/or evidence-based practice guidelines.
What drug is being prescribed? Aveed Other ___________________________________
1.
Indicate prescribed dose and frequency: _________________________________________________________
2.
What is the patient's diagnosis?
Primary hypogonadism
Hypogonadotropic hypogonadism
Other _____________________________________________________
3.
What is the ICD code? ________________
What is the patient's gender? Male Female
4.
5.
What is the patient's age? ________________ years of age
6.
Prior to initiating Aveed therapy, did the patient have at least two confirmed (pre-treatment) low morning serum
total testosterone concentrations based on reference lab range or current practice guidelines?
Yes No Unknown Action Required: Attach serum testosterone levels.
Will the patient be observed and provided appropriate medical treatment in the event of serious pulmonary oil
7.
microembolism (POME) reactions or anaphylaxis? Yes No
I attest that this information is accurate and true, and that documentation supporting this
information is available for review if requested by CVS Caremark or the benefit plan sponsor.
X_______________________________________________________________________
Prescriber or Authorized Signature
Date (mm/dd/yy)