PA Request Criteria

HMSA ASO ED PDE-5 inhibitors (Custom)

This fax machine is located in a secure location as required by HIPAA regulations. Fax complete signed and dated forms to CVS/Caremark at 855-762-5207. Please contact CVS/Caremark at 855-240-0543 with questions regarding the prior authorization process. When conditions are met, we will authorize the coverage of ED PDE-5 inhibitors (Custom).

Patient Information Patient Name:

Patient Phone: - -

Patient ID:

Patient Group No:

Patient DOB: / / Prescribing Physician

Physician Name:

Physician - - Phone:

Physician Fax: - -

Physician Address:

City, State, Zip: Drug Name (select from list of drugs shown) Levitra (vardenafil) Sildenafil Citrate Tablets Staxyn (vardenafil ODT) Stendra (avanafil) Viagra (sildenafil) Quantity: ______Frequency: ______Strength: ______Route of Administration: ______Expected Length of Therapy: ______Diagnosis: ICD Code: ______

Comments: ______Please check the appropriate answer for each applicable question. 1. Is the requested medication being used for the treatment of erectile dysfunction in a Y N patient who is 18 years of age or older?

2. Does the patient have the diagnosis of erectile dysfunction due to neurogenic etiology Y N (e.g., diabetes, chemotherapy, spinal cord injury, spina bifida, multiple sclerosis, Parkinson's disease, radical prostatectomy, resection of rectum, seizure disorder)?

3. Does the patient have the diagnosis of erectile dysfunction due to vasculogenic etiology Y N (e.g., atherosclerosis, cerebrovascular accident, coronary artery disease [CAD], dialysis procedure, hypertension, irradiation, secondary premature ejaculation, venous leakage, vascular disease)?

I attest that the medication requested is medically necessary for this patient. I further attest that the information provided is accurate and true, and that the documentation supporting this information is available for review if requested by the claims processor, the health plan sponsor, or, if applicable a state or federal regulatory agency. ______Prescriber (Or Authorized) Signature and Date Now you can get responses to drug PAs immediately and securely online—without faxes, phone calls, or waiting. How? With electronic prior authorization (ePA)! For more information and to register, go to www.caremark.com/epa.