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)