01/03/2012 <%PANumber%>
MEDIGOLD (MEDICARE) 1307
Adcirca (Medicare Prior Authorization)

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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 Adcirca (Medicare Prior Authorization).
Drug Name (select from list of drugs shown)
Adcirca (tadalafil)
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. Does the patient have a diagnosis of pulmonary arterial hypertension (PAH), (WHO Group 1)?
    Y   N    
   [If no, then no further questions.]
  2. Has PAH been confirmed by right heart catheterization?
    Y   N    
   [If yes, then skip to question 5.]
  3. Is the patient an infant with any of the following conditions?
    Y   N    
   Post cardiac surgery / Chronic lung disease associated with prematurity / Chronic heart disease / Congenital diaphragmatic hernias
   [If no, then no further questions.]
  4. Has Doppler echocardiogram been performed to diagnose PAH?
    Y   N    
   [If no, then no further questions.]
  5. Does the patient require nitrate therapy on a regular OR on an intermittent basis?
    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