Strictly confidential

Strictly Confidential
ERECTILE DYSFUNCTION MEDICATION Prior Authorization Form
Fax completed form to 1-902-481-7114
Or Mail to: MHCSI, 201 Brownlow Avenue, Unit 20
Dartmouth, NS B3B 1W2

This form must be completed IN FULL and submitted to MHCSI to permit authorization for coverage of an erectile
dysfunction medication on your employer-sponsored drug plan. Coverage will be granted if criteria are met and
erectile dysfunction medications are benefits of your plan. Approval will apply to all medications in the erectile
dysfunction category up to plan quantity and/or dollar amount as per plan design. Once approval is granted,
coverage will automatically reset yearly based on calendar or benefit year, and according to quantity/dollar limits as
per plan design.

PATIENT INFORMATION

NAME:__________________________________DATE OF BIRTH ___ ____________________
ADDRESS:____________________________________________________________________________ ____________________________________________________________________________ MHCSI CARD NUMBER:___________________________/______________________________________
Coordination of benefits (COB):  NO  YES If yes, Name of Coordinating Plan ____________________
If MHCSI, please provide: _ __________/___________ ______________________
(GROUP #)

Is this drug being covered by the coordinating plan?  NO  YES

I hereby authorize any licensed prescriber, other healthcare professional, institution, insurance company, patient access
program, plan sponsor/administrator and MHCSI to exchange information in connection with this claim for the purpose of
Prior Authorization evaluation, adjudication of claims, and administration of my drug benefit program. A photocopy of this
authorization shall be as valid as the original. I certify that the information in this form is true and complete.
Signature
Date(YYYY/MM/DD)
X
CRITERIA FOR COVERAGE

Patients are eligible for coverage of approved erectile dysfunction medications if they meet the following criteria:
1. A confirmed diagnosis of erectile dysfunction (the consistent inability to attain or sustain an erection sufficient
for sexual intercourse) due to one or more of several recognized etiologies. continued on next page
MHCSI ED PA Form 2011- Updated December 1, 2011 TO BE COMPLETED BY MEDICAL PRACTITIONER

Dear Prescribing Medical Practitioner: We appreciate you providing information on this patient’s medical condition and medication
history which is required by the drug plan sponsor for authorization of claims for erectile dysfunction medications. Please
complete the following sections of this form IN FULL. Any costs incurred in the completion of this form are the responsibility of
the patient.
Medication Requested -generic brand may be used where available
Drug Name
Strength
Staxyn (vardenafil) orally disintegrating tablet MUSE (medicated intraurethral delivery system)
This patient has a confirmed diagnosis of erectile dysfunction (the consistent inability to attain or sustain
an erection sufficient for sexual intercourse) due to:
_____
Documented side effect from (a) medically necessary prescription medication(s) Please specify:__________________________________________________ Diabetes mellitus (on oral hypoglycemics or insulin therapy) Aorta-iliac disease with evidence of decreased blood flow (e.g. abnormal Doppler studies or absent pulses) Post radical prostatectomy and radiation of the prostate Neurological injury or disease (e.g. Multiple Sclerosis, spinal cord injury) Documented endocrine abnormalities (i.e. low testosterone) Psychiatric disorder for which medication and/or treatment is being received Other , Please specify: _______________________________________________________________________
In addition to the above, the patient:
_____Yes
Has received a prescription for any form of nitrates in the past 6 months. If yes, and your request is for Viagra, Cialis or Levitra, please document the circumstances in the space provided: Is currently receiving active therapy for erectile dysfunction with any of the following: intracavernosal injections, MUSE, Viagra, Cialis, Levitra, yohimbine, vacuum device, penile implant.
Prescriber Name/Signature:
Pharmacist Name/Signature:
Store # & Location/ Phone # :
OFFICE USE ONLY
Approval
Quantity
 Accepted
 Declined
Approved by
and/or End date
Processing Number
Extension possible  Yes  No

MHCSI ED PA Form 2011- Updated December 1, 2011

Source: https://www.mhcsibenefits.ca/pdf_files/prior/Erectile%20Dysfunction%20PA%20Form%202011.pdf