01/04/2012 <%PANumber%>
MEDIGOLD (MEDICARE) 1307
Ampyra (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 Ampyra (Medicare Prior Authorization).
Drug Name (select from list of drugs shown)
Ampyra (dalfampridine)
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 multiple sclerosis?
    Y   N    
   [If no, no further questions.]
  2. Is the patient’s creatinine clearance less than or equal to 50 mL/minute?
    Y   N    
   [If yes, no further questions.]
  3. Does the patient have a history of seizures?
    Y   N    
   [If yes, no further questions.]
  4. Is the prescribed dose greater than 10 mg twice daily?
    Y   N    
   [If yes, no further questions.]
  5. Is the patient currently on treatment with Ampyra?
    Y   N    
   [If yes, skip to question 8.]
  6. Prior to initiating treatment with Ampyra, did the patient have sustained walking impairment?
    Y   N    
   [If no, no further questions.]
  7. Is the patient able to walk 25 feet (with or without assistance)?
    Y   N    
   [No further questions.]
  8. Has the patient experienced an improvement in walking speed or other objective measure of walking ability since starting Ampyra?
    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