Tricare pharmacy program medical necessity form for glaucoma agents

US Family Health Plan Prior Authorization Request Form
for Viagra (sildenafil)
Page 1 of 2
To be completed and signed by the prescriber. To be used only for prescriptions which are to be fil ed through the Department of Defense (DoD) US Family Health Plan pharmacy program (USFHP). • The provider may call: 
or the completed form may be faxed to:
• The patient may attach the completed form to the prescription and mail it to: ATTN: Pharmacy, 77 Warren St, Brighton, MA 02135 Prior authorization criteria and a copy of this form are available at: http://usfamilyhealth.org/for-providers/downloadable-forms. This prior authorization has no expiration date. Step Please complete patient and physician information (please print):
1 Patient Name:
Step Please consider the following:
Patients taking nitrates, either regularly or intermittently, should not receive PDE-5 inhibitors. Patients should be informed of the consequences should they initiate nitrate therapy while taking a PDE-5 inhibitor. • Please see product labeling precautions for concurrent use with alpha blockers. Step 1. Please indicate the patient's gender.
Please go to Section 1 for Female patients on this page
Please go to Section 2 for Male patients on page 2
Section 1 – Female patients
1. Is the PDE-5 inhibitor being prescribed for the
treatment of sexual dysfunction?
Coverage not approved
Proceed to Question 2
2. Is the PDE-5 inhibitor being prescribed for a
diagnosis of pulmonary arterial hypertension (PAH)?
Proceed to Question 4
Proceed to Question 3
3. Is the PDE-5 inhibitor being prescribed for a
diagnosis of Raynaud’s phenomenon?
Proceed to Question 4
Coverage not approved
4. What is the dosing regimen?

Please go to Step 4 on Page 2.
US Family Health Plan Prior Authorization Request Form
for Viagra (sildenafil)
Page 2 of 2
Section 2 – Male patients
1. Is the patient 18 years of age or older?
Proceed to Question 2
Proceed to Question 7
2. Is the patient 40 years of age or older?
Do not submit form.
Proceed to Question 3
3. Is Viagra being prescribed for the treatment of
erectile dysfunction of organic origin or mixed
organic/psychogenic origin?
Sign and date below
Proceed to Question 4
4. Is Viagra being prescribed for the treatment of
drug-induced erectile dysfunction where the
Proceed to Question 5
causative drug cannot be altered or
Sign and date below
discontinued?
5. Is Viagra being prescribed for preservation or
restoration of erectile function following
prostatectomy?
Proceed to Question 6
to Question 8
6. Is Viagra being prescribed for a diagnosis of
Raynaud’s phenomenon?
Proceed to Question 7
to Question 8
7. Is Viagra being prescribed for a diagnosis of
pulmonary arterial hypertension (PAH)?
Proceed to Question 8
Coverage not approved
8. What is the dosing regimen?
I certify the above is correct and accurate to the best of my knowledge. Please sign and date:

Source: http://usfamilyhealth.org/staging/wp-content/uploads/2011/07/PAF_VIAGRA_20120418.pdf