2. Does the member have a diagnosis of central precocious puberty? Y N

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1 Pharmacy Prior Authorization AETA BETTER HEALTH PESLVAIA & AETA BETTER HEALTH KIDS Leuprolide (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax signed forms to Aetna Better Health Pennsylvania / Aetna Better Health Kids at When conditions are met, we will authorize the coverage of Leuprolide (Medicaid). Please note that all authorization requests will be reviewed as the AB rated generic (when available) unless states otherwise. Drug ame (circle drug) Leuprolide acetate solution for injection Other, specify drug Quantity Frequency Strength Route of administration Expected length of therapy Patient information Patient name: Patient ID: Patient Group o.: Patient DOB: Patient phone: Prescribing physician Physician name: Specialty: PI number: Physician fax: Physician phone: Physician address: City, state, zip: Diagnosis: ICD Code: Circle the appropriate answer for each question. Question Circle es or o 1. Has this plan authorized this medication in the past for this member (i.e., previous authorization is on file under this plan)? [If no, skip to question 9.] 2. Does the member have a diagnosis of central precocious puberty? [If no, skip to question 5.] 3. Is the request for a female member who is less than 11 years of age or a male member who is less than 12 years of age? Reference umber: C13408-A / Effective Date: 10/15/2018 1

2 Circle es or o 4. Is the member demonstrating a clinical response to treatment as demonstrated by any of the following? A) Pubertal slowing or decline, B) Suppression of estradiol/testosterone levels, or C) ormalization of bone age/height velocity Please document all that apply: [o further questions.] 5. Does the member have a diagnosis of advanced prostate cancer? [If no, skip to question 7.] 6. Has the member received the requested drug for less than 2 years? [o further questions] 7. Does the member have a diagnosis of gender dysphoria/gender incongruence? 8. Has the member had a response to treatment? ote: Lab results to support response to treatment (i.e., FSH, LH, weight, height, Tanner stage (if applicable), bone age (if applicable)) are required. [o further questions.] 9. Does the member have a diagnosis of central precocious puberty? [If no, skip to question 17.] 10.Is therapy being prescribed by or in consultation with an endocrinologist? 11.Has an MRI or CT scan been performed to rule out brain lesions or tumors? 12.Did the member have onset of secondary sexual characteristics earlier than 8 years of age for a female member and 9 years of age for a male member? 13.Has the diagnosis been confirmed by a response to a GnRH stimulation test, Reference umber: C13408-A / Effective Date: 10/15/2018 2

3 Circle es or o or if not available, other labs to support the diagnosis of CPP such as luteinizing hormone levels, estradiol and testosterone level? If yes, document test results and date drawn: 14. Is the member s bone age advanced at least 1 year beyond the chronological age? If yes, document date of test, chronological age at the time of test, and bone age: 15. Have a baseline height and weight been provided? Please document date, height and weight: 16. Is the request for a female member who is less than 11 years of age or a male member who is less than 12 years of age? [o further questions.] 17. Does the member have a diagnosis of advanced prostate cancer? [If no, skip to question 20.] 18. Is the member at least 18 years old? 19. Is the requested drug being prescribed by or in consultation with an oncologist or urologist? [o further questions.] 20.Is therapy being requested for treatment of a member with gender dysphoria/gender incongruence? 21. Is the diagnosis of gender dysphoria supported by the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria and an International Classification of Diseases (ICD) code? Reference umber: C13408-A / Effective Date: 10/15/2018 3

4 Circle es or o 22.Is therapy being prescribed by or in consultation with a pediatric endocrinologist, adolescent medicine specialist or medical provider with experience and/or training in transgender medicine that has collaborated care with a mental health provider (MHP)? 23.Has documentation of collaboration with a (Mental Health Provider) MHP been attached to this request? 24. Is the request for a member 18 years of age or older? [If yes, skip to question 30.] 25. Is the request for a member who exhibits signs of puberty and has reached at least Tanner stage 2? 26.Has the member made a fully informed decision and given consent? 27. Has the member s parent/guardian provided consent to treatment? [ote: When parental consent cannot be obtained, exceptions will be reviewed on a case by case basis and in conjunction with the behavioral health provider] 28. Are the member s comorbid conditions reasonably controlled? [ote: If there are no comorbid conditions, please answer es.] 29. Has the member been educated on any contraindications and side effects to therapy? [If yes, skip to question 32.] 30. Is the request for a member who has the capacity to make a fully informed Reference umber: C13408-A / Effective Date: 10/15/2018 4

5 decision and is consenting to treatment? Circle es or o 31.Are mental health concerns, if present, reasonably well controlled? [ote: If there are no mental health concerns, please answer es.] 32. Has the member been informed of fertility preservation options prior to treatment? Comments: I affirm that the information given on this form is true and accurate as of this date. Prescriber (Or Authorized) Signature Prescriber (Or Authorized) Signature Date Date Reference umber: C13408-A / Effective Date: 10/15/2018 5