PLEASE COMPLETE CORRESPONDING SECTION FOR THESE SPECIFIC DRUGS/CLASSES LISTED BELOW AND
CIRCLE THE APPROPRIATE ANSWER OR SUPPLY RESPONSE.
ANTIFUNGALS: LAMISIL, SPORANOX, PENLAC, DIFLUCAN
Does the patient have secondary medical risk factors? Please specify which risk factor(s):
If the patient has a diagnosis of Onychomycosis, does the infection involve the toenails, fingernails or both? Please circle
If the diagnosis is Tinea corporis or Tinea cruris, does the patient require systemic therapy or have more extensive superficial
infections?
Yes
No
ANTIEMETIC (5-HT3) AGENTS: (Ondansetron quantities of 12 or less per 30 days do not require a prior authorization)
Is the patient receiving moderate to highly emetogenic chemotherapy? Monthly frequency
Yes
No
Is the patient receiving radiation therapy? Monthly frequency
Yes
No
If the patient has a diagnosis of Hyperemesis Gravidarum, has the patient experienced an inadequate treatment response to two
of the following medications?
vitamin B6, doxylamine, promethazine (Phenergan), trimethobenzamide (Tigan) or metoclopramide (Reglan)?
Yes
No
CELEBREX:
Is the patient at risk for a severe NSAID-related gastrointestinal (GI) adverse event (e.g., NSAID associated gastric ulcer, GI bleed)?
Yes
No
ERECTILE DYSFUNCTION: CIALIS, LEVITRA, VIAGRA, ALPROSTADIL
Does the patient require nitrate therapy on a regular OR on an intermittent basis, or is the patient currently taking another
ED medication?
Yes
No
If a diagnosis of erectile dysfunction, is it due to neurogenic etiology, vasculogenic etiology, psychogenic etiology or mixed
etiology? Please circle.
Is it being used for symptomatic Benign Prostatic Hyperplasia (BPH)?
Yes
No
PROTON PUMP INHIBITORS:
Does the patient have frequent and severe symptoms of GERD (e.g., heartburn, regurgitation)?
Yes
No
Does the patient have atypical symptoms or complications of GERD (e.g., dysphagia, hoarseness, erosive esophagitis)?
Yes
No
PROTOPIC:
Has the patient had a therapeutic failure of a topical corticosteroid?
Yes
No
PROVIGIL/NUVIGIL:
If the patient has a diagnosis of Obstructive Sleep Apnea, is the patient currently using a continuous positive airway pressure
(CPAP) machine or other device?
Yes
No
STIMULANTS: AMPHETAMINES, METHYLPHENIDATES, STRATTERA
Is this a renewal of therapy?
Yes
No
TAZORAC/ TRETINOIN PRODUCTS:
Has the patient tried and failed products from the following categories: Salicylic Acid Products OR Benzoyl Peroxide products?
Yes
No
TRIPTANS:
Is the patient currently using migraine prophylactic therapy (e.g., amitriptyline, propranolol, timolol)?
Yes
No
GR-68988 (1-14) V1
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