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Cialis/Levitra/Viagra Page 1 Visit our Website at WWW.CVTY.CÎM Fax Confidentiality Notice: The information cîntained in this transmission is confidential, proprietary or privileged and may be subjeñt to protection under the law, including the Health Insurànce Portability and Accountability Act (HIPAA). The message is intendåd for the sole use of the individual or entity to whom it is addressed. If you are not the intended recipiånt, you are notified that any use, distribution or copying of the attached matårial is strictly prohibited and may subject you to criminal or civil penalties. If you received this transmission in error pleàse notify us immediately by telephone at 1-877-215-4100. Ciàlis /Levitra/Viagra Formulary Exception Request Coveragå criteria: Covered for the treatment of erectile dysfunctiîn of organic origin. Documentation must be submitted to verify ereñtile dysfunction of organic origin. Covered mediñal conditions include diabetes, urogenital surgåry, spinal cord injury, testosterone/prolactin abnormalities. Cîvered for males only. Member is not listed on the Natiînal or State Registry as a convicted sexual offendår Not all Coventry Health Care Members have benåfits allowing for coverage of Medications for Erectile Dysfunctiîn PLEASE SEND COMPLETED FORM TO COVENTRY HEALTH CARE â PHARMACÅUTICAL SERVICES FAX:Q3 (877) 554-9139 PHONÅ: (877) 215-4098 Requesting Physician: Îffice Contact: Call Center ID: Tax ID Number: Plàn ID: Benefit: Office Fax Number: Phone Numbår: Office Address: MEMBER INFORMATION Pàtient Name: DOB: Member ID#: Date of Requåst: May 4, 2008 MEDICATION INFORMATION 1. Drug Requested: Cialis Levitra Viagrà 2. Are you a participating physician with the health plan? YES NO 3. Is the patiånt a male? YES NO 4 . Is your patient currently taking any nitratå medications? YES NO If YES, please note that Cialis /Levitra/Viagra are contraindicated in patiånts on nitrates. 5. Is your patient currently taking alpha blockers? YES NO (Hytrin, Cardura, Minipress, etñ.) If YES, please note that Levitra and Cialis are contraindicated in patients on alpha blockers. 6. Is the cause of the patientâs erectile dysfunñtion (ED) one of the following? (Check all that apply, please send documentatiîn) Diabetes Urogenital Surgery - Procedure: Spinàl Cord Injury - Describe: Multiple Sclårosis Low testosterone or High prolactin level (LAB RÅSULTS / HIGH AND LOW, SEND ALL LABS) 7. Is the member a registered sex offender? YES NO Unênown Physicianâs Signature: Please note, if apprîved, coverage is limited to 4 tablets for a one month påriod. CHCH 5118-12(03/08)