Erectile Dysfunction Prior Authorization Request Form ...

OptumRx has partnered with CoverMyMeds to receive prior authorization requests, saving you time and often delivering real-time determinations.

Visit go.OptumRx to begin using this free service. Please note: All information below is required to process this request.

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Erectile Dysfunction Prior Authorization Request Form (Page 1 of 2)

DO NOT COPY FOR FUTURE USE. FORMS ARE UPDATED FREQUENTLY AND MAY BE BARCODED

Member Information (required)

Provider Information (required)

Member Name:

Provider Name:

Insurance ID#:

NPI#:

Specialty:

Date of Birth:

Office Phone:

Street Address:

Office Fax:

City:

State:

Zip:

Office Street Address:

Phone:

City:

State:

Zip:

Medication Name: Check if requesting brand

Medication Information (required)

Strength:

Directions for Use:

Dosage Form:

Clinical Information (required)

Your patient's pharmacy benefit program is administered by UnitedHealthcare, which uses OptumRx for certain pharmacy benefit services. Your patient's benefit plan requires that we review certain requests for coverage with the prescribing physician. This includes requests for benefit coverage beyond plan specifications. Please complete the following questions and then fax this form to the toll free number listed below. Upon receipt of the completed form, prescription benefit coverage will be determined based on the benefit plan's rules.

Select the requested drug below: Cialis (tadalafil) Levitra (vardenafil) Muse Staxyn (vardenafil orally disintegrating tablet [ODT]) Stendra Viagra (sildenafil)

Continuation of therapy*,?: Is this request for continuation of therapy? Yes No Will medical records be submitted documenting any of the information below? Yes No

Has the member been on the requested medication in the last 180 days or is currently stabilized? Yes No Has the requested medication been safe and effective in treating the member's medical condition? Yes No Has the member tried another prescription drug in the same pharmacological class or same mechanism of action? Yes No Were prior medications discontinued due to a lack of efficacy or effectiveness, diminished effect, or an adverse event? Yes No

Select the diagnosis below*: Benign prostatic hyperplasia (BPH) Erectile dysfunction (ED) Other diagnosis: _____________________________

ICD-10 Code(s): _____________________________________

Clinical information*: Is the member receiving any form of nitrate therapy? Yes No Is the member concurrently receiving an alternative phosphodiesterase-5 enzyme inhibitor (e.g., Cialis, Levitra, Staxyn, Stendra, or Viagra)? Yes No Does the member have an organic cause(s) of erectile dysfunction? Yes No If yes, select all that apply:

Atherosclerosis

Hypercholesterolemia

Drug induced ED

Hypertension

Diabetes mellitus

Endocrine disorder including hypogonadism

History of male genital surgery (including prostatectomy, trauma, or irradiation)

Other____________________

Neurological disease (stroke, seizure disorder, demyelinating disease, spinal cord injury, tumor)

Renal insufficiency Vascular or neurologic disease affecting the genitalia

For Cialis (tadalafil) 2.5mg or 5mg requests, answer the following*:

Has the member had a history of failure following a trial for at least 4 weeks, contraindication or intolerance to an alpha-adrenergic blocking medication [e.g., Cardura, Flomax, Hytrin, Rapaflo, or Uroxatral]? Yes No

______________________________________________________________________________________________________________

This document and others if attached contain information that is privileged, confidential and/or may contain protected health information (PHI). The Provider named above is required to safeguard PHI by applicable law. The information in this document is for the sole use of OptumRx. Proper consent to disclose PHI between these parties has been obtained. If you received this document by mistake, please know that sharing, copying, distributing or using information in this document is against the law. If you are not the intended recipient, please notify the sender immediately. Office use only: ErectileDysfunction_UHCEI_2019Jul-W

Erectile Dysfunction Prior Authorization Request Form (Page 2 of 2)

DO NOT COPY FOR FUTURE USE. FORMS ARE UPDATED FREQUENTLY AND MAY BE BARCODED

Medication history*: For brand Cialis requests, answer the following: Does the member have a history of failure, contraindication, or intolerance to tadalafil (generic Cialis)**? Yes No For brand Levitra requests, answer the following: Does the member have a history of failure, contraindication, or intolerance to vardenafil (generic Levitra)**? Yes No For brand Viagra requests, answer the following: Does the member have a history of failure, contraindication, or intolerance to sildenafil (generic Viagra)**? Yes No For Staxyn (vardenafil ODT) requests, answer the following: Does the member have a history of failure, contraindication, or intolerance to vardenafil (generic Levitra)**? Yes No For Stendra requests, select the medications the member has a history of failure, contraindication or intolerance to (List the date of trial and the reason for failure to each medication):

Sildenafil (generic Viagra)** Tadalafil (generic Cialis)** Vardenafil (generic Levitra)**

Date of trial:_______________ Date of trial:_______________ Date of trial:_______________

Reason:______________________________________________ Reason:______________________________________________ Reason:______________________________________________

Reauthorization*: If this is a reauthorization request, answer the following: Is the member currently on the requested medication? Yes No Is there documentation the member has had a positive clinical response to therapy? Yes No

Quantity limit requests*: For Cialis (tadalafil) 2.5mg or 5mg requests, answer the following: What is the quantity requested per MONTH? ________ Is the member using Cialis (tadalafil) once a day for the treatment of BPH? Yes No

Prescriber attestation:

Does the prescriber attest that the information provided is true and accurate to the best of their knowledge and understand that UnitedHealthcare may perform a routine audit and request the medical information necessary to verify the accuracy of the information provided? Yes No

Prescriber's signature: ______________________________ Date: _________________

* May not apply to all plans ** This product may require prior authorization ? Please note: Chart documentation of the above is required to be submitted along with this fax form

Are there any other comments, diagnoses, symptoms, medications tried or failed, and/or any other information the physician feels is important to this review?

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

Please note:

This request may be denied unless all required information is received within established timelines. For urgent or expedited requests please call 1-800-711-4555. This form may be used for non-urgent requests and faxed to 1-800-527-0531.

______________________________________________________________________________________________________________

This document and others if attached contain information that is privileged, confidential and/or may contain protected health information (PHI). The Provider named above is required to safeguard PHI by applicable law. The information in this document is for the sole use of OptumRx. Proper consent to disclose PHI between these parties has been obtained. If you received this document by mistake, please know that sharing, copying, distributing or using information in this document is against the law. If you are not the intended recipient, please notify the sender immediately. Office use only: ErectileDysfunction_UHCEI_2019Jul-W

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