Pa form

HMSA FED PLAN
This fax machine is located in a secure location as required by HIPAA regulations.
Complete/review information, sign and date. Fax signed forms to CVS/Caremark at 1-855-762-5207.
Please contact CVS/Caremark at 1-855-240-0543 with questions regarding the prior authorization process.
When conditions are met, we will authorize the coverage of Cialis / Levitra / Viagra.
Drug Name (select from list of drugs shown) Please circle the appropriate answ er for each question.
Is the patient at least 18 years of age or older? Does the patient have the diagnosis of erectile dysfunction due to neurogenic etiology (e.g., diabetes, chemotherapy, spinal cord injury, spina bifida, multiple sclerosis, Parkinson’s disease, radicalprostatectomy, resection of rectum, seizure disorder)? [If the answer to this question is yes, then skip to question 7.] Does the patient have the diagnosis of erectile dysfunction due to vasculogenic etiology (e.g., atherosclerosis, cerebrovascular accident, coronary artery disease [CAD], dialysis procedure,hypertension, irradiation, secondary premature ejaculation, venous leakage, vascular disease)? [If the answer to this question is yes, then skip to question 7.] Does the patient have the diagnosis of erectile dysfunction due to psychogenic etiology (e.g., depression, [If the answer to this question is yes, then skip to question 7.] Does the patient have the diagnosis of erectile dysfunction due to mixed etiology (e.g., benign prostatic hyperplasia [BPH], prostate cancer, combination of neurogenic, vasculogenic, or psychogenic)? [If the answer to this question is no, then skip to question 15.] Has the patient had a complete and thorough medical history and exam to evaluate the underlying medical cause of erectile dysfunction, as well as general health? Is the patient using other pharmacological treatments for erectile dysfunction? [If the answer to this question is no, then skip to question 10.] Will the patient discontinue other pharmacological treatments for erectile dysfunction? Is the request for a phosphodiesterase type 5 (PDE-5) Inhibitor (e.g., Cialis, Levitra, Staxyn, Stendra, [If the answer to this question is yes, then skip to question 12.] Does the patient have any of the following contraindications to the use of alprostadil: condition that may predispose to priapism (such as sickle cell anemia or trait, multiple myeloma, leukemia); anatomicaldeformation of the penis (such as angulation, cavernosal fibrosis, Peyronie’s disease); condition wheresexual activity is inadvisable (such as fragile cardiac status); or penile implants? Does the patient require nitrate therapy on a regular OR on an intermittent basis? Is this request for the treatment of symptomatic benign prostatic hyperplasia (BPH) (e.g., incomplete emptying, weak stream, straining, urinary frequency, intermittency, urgency, or acute urinary retention)WITH erectile dysfunction (ED)? [If the answer to this question is no, then no further questions are required.] Is this request for daily use of Cialis 2.5mg or Cialis 5mg tablets? Is this request for the treatment of symptomatic benign prostatic hyperplasia (BPH) (e.g., incomplete emptying, weak stream, straining, urinary frequency, intermittency, urgency, or acute urinary retention)WITHOUT erectile dysfunction (ED)? Does the patient require nitrate therapy on a regular OR on an intermittent basis? Is this request for daily use of Cialis 2.5mg or Cialis 5mg tablets? I affirm that the information given on this form is true and accurate as of this date.
Prescriber (Or Authorized) Signature and Date

Source: http://www.hmsa.com/PORTAL/PROVIDER/CVS_Cialis_Levitra_Viagra_Prior_Auth_122712.pdf