PRIOR AUTHORIZATION REQUEST FORM EOC ID EIC 2013 Cialis Prior Authorizationr r rPhone 866-250-2005 Fax back to 877-503-7231 ENVISION RX OPTIONS manages the pharmacy drug benefit for your patient. Certain requests for coverage require review with the prescribing physician* Please answer the following questions and fax this form to the number listed above. Please note any information left blank or illegible may delay the review process. Patient Name NA Prescriber Name NA Member Number Fax Date of Birth Office Contact Group Number NPI Address City State Zip Phone State Lic ID Member Phone rExpedited/Urgent Drug Name Directions Please attach any pertinent medical history or information for this patient that may support approval* Please answer the following questions and sign Q1. Is request for initial or continuing therapy Initial Therapy Continuing Therapy. r Q2. Please indicate the patient s diagnosis Benign prostatic hyperplasia. rErectile dysfunction. rOther please specify Cialis 2. 5 mg rCialis 10 mg rOther please specify Q4. Patient has tried and failed an alpha blocker rRapaflo rterazosin rdoxazosin rAvodart rJalyn Q6. Prescriber may provide any supporting clinical statements such as chart notes lab values adverse outcomes treatment failures or any other additional clinical information to support an authorization request. Physician Signature Date This telecopy transmission contains confidential information belonging to the sender that is legally privileged* This information is intended only for the use of the individual or entity named above. The authorized recipient of this information is prohibited from disclosing this information to any other party. If you are not the intended recipient you are hereby notified that any disclosure copying distribution or action taken in reference to the contents of this document is strictly prohibited* If you have received this telecopy in error please notify the sender immediately to arrange for the return of this document. Certain requests for coverage require review with the prescribing physician* Please answer the following questions and fax this form to the number listed above. Please note any information left blank or illegible may delay the review process. Patient Name NA Prescriber Name NA Member Number Fax Date of Birth Office Contact Group Number NPI Address City State Zip Phone State Lic ID Member Phone rExpedited/Urgent Drug Name Directions Please attach any pertinent medical history or information for this patient that may support approval* Please answer the following questions and sign Q1. Please note any information left blank or illegible may delay the review process. Patient Name NA Prescriber Name NA Member Number Fax Date of Birth Office Contact Group Number NPI Address City State Zip Phone State Lic ID Member Phone rExpedited/Urgent Drug Name Directions Please attach any pertinent medical history or information for this patient that may support approval* Please answer the following questions and sign Q1. Is request for initial or continuing therapy Initial Therapy Continuing Therapy. r Q2. Please indicate the patient s diagnosis Benign prostatic hyperplasia.