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Cialis/Levitra/Viagra Formulary Exception Request
Coverage criteria: Covered for the treatment of erectile dysfunction of organic origin.
Documentation must be submitted to verify erectile dysfunction of organic origin. Covered medical conditions include diabetes, urogenital surgery, spinal cord injury, testosterone/prolactin abnormalities. Member is not listed on the National or State Registry as a convicted sexual offender Not all Coventry Health Care Members have benefits allowing for coverage of
Medications for Erectile Dysfunction
PLEASE SEND COMPLETED FORM TO COVENTRY HEALTH CARE – PHARMACEUTICAL SERVICES
F AX : Q 3 ( 877) 554- 9139 P HO NE : ( 877) 215- 4098
MEMBER INFORMATION
MEDICATION INFORMATION
1. Drug Requested: Cialis o Levitra o Viagra o
2. Are you a participating physician with the health plan? YES o NO o
3. Is the patient a male? YES o NO o
Is your patient currently taking any nitrate medications? YES o NO o
4.
If YES, please note that Cialis/Levitra/Viagra are contraindicated in patients on nitrates.
Is your patient currently taking alpha blockers? YES o NO o
5. (Hytrin, Cardura, Minipress, etc.)
If YES, please note that Levitra and Cialis are contraindicated in patients on alpha blockers.
Is the cause of the patient’s erectile dysfunction (ED) one of the following?
(Check all that apply, please send documentation)
o Diabetes
o Urogenital Surgery - Procedure:_________________________________________
6. o Spinal Cord Injury - Describe: __________________________________________
o Multiple Sclerosis
o Low testosterone or o High prolactin level______________________________
(LAB RESULTS / HIGH AND LOW, SEND ALL LABS)
7. Is the member a registered sex offender? YES o NO o Unknown o
Please note, if approved, coverage is limited to 4 tablets for a one month period.
CHCH 5118-12(03/08)
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Source: http://altius.coventryhealthcare.com/web/groups/public/@cvty_regional_chcut/documents/document/c054187.pdf

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