Anabolic SteroidsPrior Authorization Worksheet
New York State Medicaid Clinical Drug Review Program
Instructions
Program Information
Drugs included in the Clinical Drug Review Program require prior authorization.
A list of CDRP drugs is available at and at
Prescribers are required to call the toll free telephone number 1-877-309-9493 and respond to a series of questions that identify the prescriber, the patient, and the reason for prescribing this drug.
For some drugs subject to the CDRP, only the prescriber, not an authorized agent, can call the prior authorization call line to initiate a prior authorization. An authorized agent is an employee of the prescribing practitioner and has access to the patient's medical records (i.e. nurse, medical assistant).
Please be prepared to fax validating documentation for each request to 800-268-2990.
Prescriber Procedure
Following review of all of the required information, you will be contacted by the clinical call center regarding prior authorization for Anabolic Steroids.
If your fax includes the standardized fax form, only the Member Name, ID, DOB, and Clinical Criterianeed to be completed and faxed as an attachment to process your request.
PA requests from 3rd party agencies to include faxes or any media are not allowed. Please have the prescribing physician or an agent working directly in the physician’s office contact our department for consideration of this request.
If your fax includes the standardized fax form, only the Member Name, ID, DOB, and Clinical Criterianeed to be completed and faxed as an attachment to process your request.
Enrollee InformationEnrollee Name:
enrollee Date of Birth: / enrollee medicaid id number (2 letters, 5 numbers, 1 letter):
Address: / City: / State: / Zip:
Prescriber Information
prescriber Name: / Prescriber Board Certified Specialty:
Address: / City: / State: / Zip:
prescriber 10-digit national provider identifier (NPI): / office Phone Number: / office Fax number:
Clinical Criteria- Drug Information
Drug name: / Strength:
DIRECTIONS: / QTY:
New prescription: / Yes No / If No, Date Therapy Initiated:
Clinical Criteria - Diagnosis
Hypogonadotropic or primary hypogonadism / Delayed puberty / Other:
For Diagnoses of hypogonadotropic or primary hypogonadism
1. / Does the patient have documented low testosterone concentration with two tests?
(required prior to initiation of anabolic steroid therapy) / Yes No
If yes, please provide the dates for the two tests indicating low testosterone concentrations:
/ / / / /
2. / Does the patient have documented therapeutic testosterone concentration, indicating response to therapy? (required for continuation of anabolic steroid therapy) / Yes No
If yes, please provide date(s) for tests indicating therapeutic testosterone concentrations: / / /
For Diagnoses of delayed puberty
1. / Has growth hormone deficiency been ruled out prior to initiation of anabolic steroid therapy? / Yes No
If yes, please provide date(s) for growth hormone deficiency tests: / / /
For Diagnosis of Other
Please provide clinical rationale and laboratory test results (if applicable) for the use of anabolic steroid.
Please answer the following questions if requesting a nonpreferred anabolic steroid:(a listing of preferred and nonpreferred drugs can be found at
Is there a documented history of successful therapeutic control with a nonpreferred agent? / Yes No
Has the patient experienced treatment failure or an adverse reaction with a preferred agent? / Yes No
Attestation
I attest that 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.
prescriber signature / dateNote: Processing May Be Delayed if Information Submitted is Illegible or Incomplete.
Revision Date: July 9, 2014 / Prior Authorization Call Line 1-877-309-9493
For billing questions, call 1-800-343-9000.
For clinical concerns or Clinical Drug Program Review questions, visit and
or call 1-877-309-9493. / Page 1