Forteo Injectable Medication Precertification Request

Aetna Precertification Notification
Phone: 1-800-414-2386
FAX:
1-800-408-2386
Individual Plan Forteo Injectable
Medication Precertification Request
(All fields must be completed and legible for Precertification Review)
Please indicate:
Start of treatment: Start date
/
/
Continuation of therapy: Date of last treatment
Precertification Requested By:
A. PATIENT INFORMATION
First Name:
Address:
Home Phone:
DOB:
Allergies:
/
/
Phone:
Last Name:
City:
Work Phone:
State:
ZIP:
Cell Phone:
E-mail:
Current Weight:
lbs or
B. INSURANCE INFORMATION
kgs
Aetna Member ID #:
Group #:
Insured:
Height:
inches or
Does patient have other coverage?
If yes, provide ID#:
Insured:
Medicaid:
Yes
Medicare:
Yes
No If yes, provide ID #:
C. PRESCRIBER INFORMATION
First Name:
Last Name:
Address:
City:
St Lic #:
NPI #:
Phone:
Fax:
Provider E-mail:
Office Contact Name:
Specialty (Check one):
GYN
Orthopedic
Primary Provider
Other:
D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION
Place of Administration:
Self-administered
Outpatient Infusion Center
Center Name:
Home Infusion Center
Agency Name:
Fax:
Physician’s Office
Phone:
Phone:
cms
Yes
No
Carrier Name:
No If yes, provide ID #:
(Check One):
M.D.
State:
DEA #:
N.P.
P.A.
UPIN:
Phone:
Dispensing Provider/Pharmacy: (Patient selected choice)
Physician’s Office
Retail Pharmacy
Specialty Pharmacy
Mail Order
Other:
Name:
Phone:
TIN:
Administration code(s) (CPT):
E. PRODUCT INFORMATION
D.O.
ZIP:
Fax:
PIN:
Request is for:
Forteo
F. DIAGNOSIS INFORMATION
Primary ICD Code:
Other ICD Code:
G. CLINICAL INFORMATION
Yes
Yes
No Is the patient unable to remain in an upright position during post oral bisphosphonate administration?
No Does the patient have documented treatment failure after an adequate trial of at least two oral bisphosphonates?
If yes, please check all that apply:
Yes
Fosamax or Fosamax plus D (alendronate)
Actonel or Actonel with Calcium or Atelvia (risedronate)
Didronel (etidronate)
Oral Boniva (ibandronate)
Skelid (tiludronate)
Other:
No Does the patient have documented treatment failure after an adequate trial of at least one oral bisphosphonate and one SERM?
If yes, please check all that apply:
Fosamax or Fosamax plus D (alendronate)
Actonel or Actonel with Calcium or Atelvia (risedronate)
Tamoxifen (nolvadex)
Didronel (etidronate)
Oral Boniva (ibandronate)
Evista (raloxifene)
Skelid (tiludronate)
Other:
Fareston (toremifene)
Yes
No Does the patient have a documented medical reason (intolerance, hypersensitivity, and/or contraindication) to avoid using oral
bisphosphonates or SERMS?
Yes
No Does the patient have Dysphagia (difficulty swallowing)?
Yes
No Does the patient have presence or history of osteoporotic vertebral compression fracture and/or hip fracture
Yes
No Has the patient been on Forteo for more than 2 years?
What is the patient’s T-score:
Date taken:
H. ACKNOWLEDGEMENT
Request Completed By (Signature Required):
Date:
/
/
Any person who knowingly files a request for authorization of coverage of a medical procedure or service with the intent to injure, defraud or deceive any
insurance company by providing materially false information or conceals material information for the purpose of misleading, commits a fraudulent insurance act,
which is a crime and subjects such person to criminal and civil penalties.
The plan may request additional information or clarification, if needed, to evaluate requests.
GR-69053-1 (12-14)