01/04/2012 <%PANumber%>
MEDIGOLD (MEDICARE) 1307
Anadrol-50 (Med PA)

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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 Anadrol-50 (Med PA).
Drug Name (select from list of drugs shown)
Anadrol-50 (oxymetholone)
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 this request for oxandrolone (Oxandrin)?
    Y   N    
   [If the answer to this question is yes, then skip to question 3.]
  2. Does the patient have the diagnosis of anemia due to deficient red-cell production, (e.g. acquired aplastic anemia, congenital aplastic anemia, myelofibrosis, or the hypoplastic anemias due to the administration of myelotoxic drugs)?
    Y   N    
   [If the answer to this question is yes, then skip to question 4.]
  3. Does the patient have HIV-wasting syndrome or cachexia due to a chronic disease?
    Y   N    
  4. Does the patient have known or suspected carcinoma of the prostate or breast (in male patients)?
    Y   N    
  5. Does the patient have known or suspected carcinoma of the breast in women with hypercalcemia?
    Y   N    
  6. Does the patient have known or suspected nephrosis (the nephrotic phase of nephritis)?
    Y   N    
  7. Does the patient have known or suspected hypercalcemia?
    Y   N    
  8. Is the patient pregnant?
    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