CLINICAL CRITERIA DIAGNOSIS (CONTINUED) – For other diagnoses: Please provide clinical rationale and laboratory test results (if applicable) for the use of anabolic steroid: _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ Please answer the following questions if requesting a non-preferred anabolic steroid (a listing of preferred and non-preferred can be found at ): Is a documented history of successful therapeutic control with a non-preferred agent? Yes No Has the patient experienced treatment failure or an adverse reaction with a preferred agent? Yes No Prescriber Signature (Required) Date I attest that this anabolic steroid is medically necessary for this patient and that all of the information on this form is accurate to the best of my knowledge. 1-800-268-2990 Fax Number: 1-877-309-9493 Prior Authorization Call Line: 1-800-343-9000 Billing Questions: For clinical questions or Clinical Drug Review Program questions, please visit or call 1-877-309-9493.
CLINICAL CRITERIA – DIAGNOSIS (CONTINUED) For other diagnoses: Please provide clinical rationale and laboratory test results (if applicable) for the use of anabolic steroid: _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ Please answer the following questions if requesting a non-preferred anabolic steroid (a listing of preferred and non-preferred can be found at ): Is a documented history of successful therapeutic control with a non-preferred agent? Yes No Has the patient experienced treatment failure or an adverse reaction with a preferred agent? Yes No Prescriber Signature (Required) I attest that this anabolic steroid is medically necessary for this patient and that all of the information on this form is accurate to the best of my knowledge. Date Fax Number: 1-800-268-2990 Prior Authorization Call Line: 1-877-309-9493 Billing Questions: 1-800-343-9000 For clinical questions or Clinical Drug Review Program questions, please visit or call 1-877-309-9493.
NYRx_CDRP_PA_Worksheet_Prescribers_Anabolic_Steroids.docx