01/04/2012 <%PANumber%>
MEDIGOLD (MEDICARE) 1307
Amphetamines (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 Amphetamines (Medicare Prior Authorization).
Drug Name (select from list of drugs shown)
Adderall (amphetamine mixture) Adderall XR (amphetamine mixture) Amphetamine-Dextroamphetamine
Amphetamine-Dextroamphetamine SR Dextroamphetamine ER capsules Dextroamphetamine tablets
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 patient 3 years of age or older?
    Y   N    
  2. Does the patient have a diagnosis of Attention-Deficit Hyperactivity Disorder (ADHD) or Attention Deficit Disorder (ADD)?
    Y   N    
   [If the answer to this question is yes, skip to question 6.]
  3. Is the medication being prescribed Vyvanse (lisdexamfetamine) or Desoxyn (methamphetamine)?
    Y   N    
   [If the answer to this question is yes, then no further questions are required.]
  4. Does the patient have the diagnosis of narcolepsy?
    Y   N    
   [If the answer to this question is no, then no further questions are required.]
  5. Has the diagnosis been confirmed by sleep studies?
    Y   N    
  6. Will the patient be on a monoamine oxidase inhibitor (MAOI) drug while taking this therapy or has the patient been on an MAOI drug in the previous 14 days?
    Y   N    
   [MAOI drugs include \ Phenelzine (Nardil) \ Tranylcypromine (Parnate) \ Isocarboxazid (Marplan) \ And Selegiline (Eldepryl, Emsam)]
   [If the answer to this question is no, skip to question 8.]
  7. Is the prescriber a psychiatrist with experience prescribing both monoamine oxidase inhibitor (MAOI) drugs and amphetamine/dextroamphetamine drugs?
    Y   N    
   [If the answer to this question is no, then no further questions are required.]
  8. In light of the boxed warning, has the prescriber weighed/considered the benefits of treatment versus the potential risks of serious cardiovascular events (including sudden death) associated with the use of amphetamine products?
    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