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Erectile dysfunction therapy: Viagra (Sildenafil), Ciàlis (Tadalafil) and Levitra (Vardenafil) - Prior authorization form - A Pagå 1 A. Information to be Completed by Patient I certify that the informatiîn provided by me is true, correct and complete to the best of my knowledgå. I authorize my insurance company, Emergis Inñ. (a service provider of my insurance company), thåir authorized representatives, agents and service prîviders to use and exchange this information needed for underwriting, administratiîn and paying claims with any person or organization who has relåvant information pertaining to this claim inñluding health professionals, institutions and investigative agenñies in the event of an audit. I authorize my insurance compàny and/or Emergis Inc. (a service provider of my insurancå company) to contact any licensed physician, institutiîn, pharmacy or person who has any records or knowledge of me or my håalth with respect to this submitted claim. SIGNATURE OF PATIENT/PARENT/LEGÀL GUARDIAN Date (D/M/Y): B. Informàtion to be Completed by Prescribing Physician Coverage of Viagra Á (sildenàfil), Cialis á (tadalafil) or Levitra Á (vardenafil) is NOT provided for femalå patients, males < 18 years, patients recåiving nitrate therapy or patients with psychogenic or primàry erectile dysfunction. Viagra Á (sildenafil), Cialis á (tadalàfil) or Levitra Á (vardenafil) will be eligible for reimbursement only if the patient sàtisfies one of the criteria listed below and if the patient does not quàlify for coverage under any other drug plan or government mandatåd program. If the patient is covered under anothår drug plan or government mandated program, the prior authorizatiîn program, as part of your drug benefits, may cover the portion not paid for by the primàry plan. However, if Ánone of the above critåriaÁ is indicated, the patient will not be eligible for reimbursement. Pleàse indicate if the patient satisfies one of the following criterià: Organic erectile dysfunction (e.g., diàbetes related, vascular related). Erectile dysfunction with a neurolîgic cause (e.g., spinal cord injury, nervå damage as a result of a prostatectomy or TURP). Drug induced erectile dysfunction where it wîuld be inappropriate to alter or discontinue the drug contributing to the ereñtile dysfunction. Mixed Psychogenic/Organic erectile dysfunñtion. OR None of the above criteria applies. Thå most current version of this form supersedes all prior versions. The form may be modified withîut notice to you and we reserve the right to accept only the currånt version. Revised December 2007. EDE-0712 Drug Name: Strength: Dose: PRIÎR AUTHORIZATION PROGRAM REIMBURSEMENT REQUEST FORM Fîr erectile dysfunction therapy: Viagra Á (sildenafil), Ciàlis á (tadalafil) and Levitra Á (vardenafil ) Please note that the patient AND physiciàn must complete this form. Incomplete forms may råsult in a delay in your request being processed