01/04/2012 <%PANumber%>
MEDIGOLD (MEDICARE) 1307
Anagrelide (Medicare Prior Auth)

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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 Anagrelide (Medicare Prior Auth).
Drug Name (select from list of drugs shown)
Anagrelide
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 anagrelide prescribed for the treatment of thrombocythemia?
    Y   N    
   [If no, then no further questions.]
  2. Is the thrombocythemia secondary to a myeloproliferative disorder?
    Y   N    
   [If no, then no further questions.]
  3. Does the patient have severe hepatic impairment?
    Y   N    
   [If yes, then no further questions.]
  4. Was anagrelide prescribed by or in consultation with an oncologist or hematologist?
    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