<p>11/05/2015</p><p>AETNA BETTER HEALTH OF TEXAS MEDICAID Global DUR Exceptions (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax signed forms to Aetna Better Health of Texas Medicaid (Bexar and Tarrant) at 1-844-275-1084. Please contact Aetna Better Health of Texas Medicaid (Bexar) at 1-800-248-7767 or Aetna Better Health of Texas Medicaid (Tarrant) at 1-800-306-8612 with questions regarding the Prior Authorization process. When conditions are met, we will authorize the coverage of Global DUR Exceptions (Medicaid). Please note that all authorization requests will be reviewed as the AB rated generic (when available) unless states otherwise.</p><p>Drug Name (select from list of drugs shown) Other, Please specify Quantity Frequency Strength Route of Administration Expected Length of therapy </p><p>Patient Information Patient Name: Patient ID: Patient Group No.: Patient DOB: Patient Phone:</p><p>Prescribing Physician</p><p>Physician Name: ______</p><p>Specialty: ______NPI Number: ______</p><p>Physician Fax: ______Physician Phone: ______</p><p>Physician Address: ______City, State, Zip: ______Diagnosis: ICD Code:</p><p>Please circle the appropriate answer for each question. Question Circle Yes or No 1. Is the request for a quantity limit override? Y N [If the answer to this question is no, then skip to question 4.] 2. Is the drug being prescribed within the Y N manufacturer’s published dosing guidelines? [If the answer to this question is no, then no further questions required.] 3. Can the patient use a higher strength of the Y N same medication to achieve the requested dosage? [No further questions required.] 4. Is the request due to an age edit? Y N Question Circle Yes or No 1. Is the request for a quantity limit override? Y N [If the answer to this question is no, then skip to question 6.] 5. Does the age of the patient fall within the Y N manufacturer’s prescribing information (i.e., under the maximum age and above the minimum age)? [No further questions required.] 6. Does the gender of the patient meet the Y N plan's requirements?</p><p>Comments:</p><p>I affirm that the information given on this form is true and accurate as of this date.</p><p>Prescriber (Or Authorized) Signature Date Prescriber (Or Authorized) Signature Date</p>