01/03/2012 <%PANumber%>
MEDIGOLD (MEDICARE) 1307
Adagen (Medicare Determination)

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Complete/review information, sign and date. Fax signed forms to CVS/Caremark at 1-866-239-8303.
Please contact CVS/Caremark at 1-800-294-5979 with questions regarding the prior authorization process.
When conditions are met, we will authorize the coverage of Adagen (Medicare Determination).
Drug Name (select from list of drugs shown)
Adagen (pegademase bovine inj)
Patient Information
Patient Name:    
Patient ID:    
Patient Group No.:    
Patient DOB:    
Prescribing Physician
Physician Name:    
Physician Phone:    
Physician Fax:    
Physician Address:    
City, State, Zip:    
Diagnosis:     ICD Code:  
Please circle the appropriate answer for each question.
  1. Is the physician purchasing and providing the drug “incident to” physician services (i.e., drugs supplied and administered by a physician or under a physician’s direct supervision)?
    Y   N    
   [If the answer to this question is yes, then no further questions required.]
  2. Is the patient in a long-term care (LTC) bed that is covered by Medicare?
    Y   N    
  3. Is the request for one of the following drugs via an IV infusion pump?
    Y   N    
   Acyclovir \ Foscamet \ Amphotericin B \ Fluorouracil \ Cytarabine \ Bleomycin \ Doxorubicin \ Vincristine \ Vinblastine \ Treprostinil (Remodulin) \ Cisplatin \ Gemcitabine \ Oxaliplatin \ Morphine
  4. Does the patient have a diagnosis of severe combined immunodeficiency disease (SCID)?
    Y   N    
   [If no, then no further questions.]
  5. Is SCID due to adenosine deaminase (ADA) deficiency?
    Y   N    
   [If no, then no further questions.]
  6. Does the patient have severe thrombocytopenia?
    Y   N    
   [If yes, then no further questions.]
  7. Has bone marrow transplantation failed to improve the patient’s condition?
    Y   N    
   [If yes, then no further questions.]
  8. Is the patient currently INELIGIBLE for a bone marrow transplant?
    Y   N    

Comments:  

I affirm that the information given on this form is true and accurate as of this date.

 
Prescriber (Or Authorized) Signature and Date