01/04/2012 <%PANumber%>
MEDIGOLD (MEDICARE) 1307
Androgel (Medicare Prior Authorization)

This fax machine is located in a secure location as required by HIPAA regulations.
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 Androgel (Medicare Prior Authorization).
Drug Name (select from list of drugs shown)
Androgel (testosterone td gel)
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 male?
    Y   N    
   [If the answer to this question is no, then no further questions are required.]
  2. Does the patient have confirmed or suspected carcinoma of the prostate or breast?
    Y   N    
  3. Is the patient being treated for primary hypogonadism (congenital or acquired)?
    Y   N    
   [If the answer to this question is yes, then skip to question 5.]
  4. Is the patient being treated for secondary (i.e. hypogonadotropic) hypogonadism (e.g., idiopathic gonadotropin or LHRH deficiency)?
    Y   N    
   [If the answer to this question is no, then no further questions are required.]
  5. Before the start of testosterone therapy did the patient (or does the patient currently) have a confirmed low testosterone level (i.e. morning total testosterone less than 300 ng/dL, morning free or bioavailable testosterone morning free or bioavailable testosterone less than 5 ng/dL) or absence of endogenous testosterone?
    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