Formulary Exception/prior Authorization Request Form (Page 2 of 2) in pdf

PLEASE COMPLETE CORRESPONDING SECTION FOR THESE SPECIFIC DRUGS/CLASSES LISTED BELOW AND CIRCLE THE APPROPRIATE ANSWER OR SUPPLY RESPONSE.

ANTIFUNGALS:

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 or No

If the request is for topical medication, has the patient has experienced an inadequate treatment response, intolerance, or contraindication to an oral antifungal therapy?

ANTIEMETIC (5-HT3) AGENTS:

Is the patient receiving moderate to highly emetogenic chemotherapy or receiving radiation therapy? Yes or No

If the patient has a diagnosis of Hyperemesis Gravidarum, is the patient a documented risk for hospitalization for rehydration? Yes or 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 or No

CELEBREX:

Is the patient being treated for post-operative pain following CABG surgery or have active GI bleeding? Yes or No

Has the patient received a 30 days supply of an anticoagulant, antiplatelet, an oral corticosteroid or a gastrointestinal medication? Yes or No

Has the patient had intolerance to or an inadequate treatment response to a traditional NSAID or NSAID/GI combination product? Yes or No

Is the drug being prescribed for osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, acute pain, primary dysmenorrheal, or juvenile rheumatoid arthritis? Please circle

ERECTILE DYSFUNCTION:

Does the patient require nitrate therapy on a regular OR on an intermittent basis? Yes or No

Is the drug being prescribed for erectile dysfunction ? Yes or No

Is the drug being prescribed for Pulmonary Arterial Hypertension (PAH)? Yes or No

Is the drug being prescribed for symptomatic Benign Prostatic Hyperplasia (BPH)? Yes or No

INSOMNIA AGENTS:

Have other treatable medical/psychological causes of chronic insomnia been considered and/or addressed? Yes or No

Have appropriate sleep hygiene and sleep environment issues been addressed? Yes or No

PROTON PUMP INHIBITORS:

Does the patient have peptic ulcer disease OR frequent and severe symptoms of GERD (e.g., heartburn, regurgitation) OR atypical symptoms or complications of GERD (e.g.,

dysphagia, hoarseness, erosive esophagitis? Yes or No

Does the patient have Barrett’s esophagus or a Hypersecretory syndrome (e.g. Zollinger-Ellison)? Yes or No

Is the patient at high risk for GI adverse events? Yes or No

PROVIGIL/NUVIGIL:

Does the patient have a diagnosis of Shift Work Sleep Disorder AND experience excessive sleepiness while working? Yes or No

Does the patient have a diagnosis of Obstructive Sleep Apnea, and if so, is the patient currently using a continuous positive airway pressure (CPAP) machine? Yes or No

Does the patient have a diagnosis of Narcolepsy, and if so, has the diagnosis been confirmed by sleep lab evaluation? Yes or No

STIMULANTS: AMPHETAMINES, METHYLPHENIDATES, STRATTERA

Does the patient have a diagnosis of ADHD or ADD? Yes or No

Has the diagnosis been documented (i.e., evaluated by a complete clinical assessment, using DSM-5, standardized rating scales, interviews/questionnaires)? Yes or No

Does the patient have a diagnosis of Narcolepsy, and if so, has the diagnosis been confirmed by sleep lab evaluation? Yes or No

TRETINOIN PRODUCTS:

Does the patient have the diagnosis of acne vulgaris or keratosis folliculus? Yes or No

TAZORAC

Does the patient have a diagnosis of acne or plaque psoriasis? Yes or No

If the patient is female, has the physician discussed with the patient the potential risks of fetal harm and importance of birth control while using Tazorac? Yes or No

Will the patient be applying Tazorac to less than 20 percent of body surface area? Yes or No

TESTOSTERONE PRODUCTS:

Before start of testosterone therapy did the patient (or does the patient currently) have two confirmed low testosterone levels or absence of endogenous testosterone? Yes or No

Does the patient have carcinoma of the breast or known or suspected prostate cancer? Yes or No

TRIPTANS:

Does the patient have confirmed or suspected cardiovascular or cerebrovascular disease, or uncontrolled hypertension? Yes or No

Does the patient have a diagnosis of migraine headache or cluster headache? Yes or No

Is the patient currently using migraine prophylactic therapy (e.g., amitriptyline, propranolol, timolol)? Yes or No

Has medication overuse headache been considered and ruled out? Yes or No