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

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When conditions are met, we will authorize the coverage of Androxy (Medicare Prior Auth).
Drug Name (select from list of drugs shown)
Androxy (fluoxymesterone)
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. Has the patient tried and failed or is the patient unable to tolerate non-oral forms of testosterone supplementation?
    Y   N    
  2. Is the patient female?
    Y   N    
   [If the answer to this question is no, then skip to question 6.]
  3. Is the patient being treated for inoperable metastatic breast cancer?
    Y   N    
  4. Is the patient 1 to 5 years postmenopausal (naturally or surgically)?
    Y   N    
  5. Has the patient had an incomplete response to other therapy for metastatic breast cancer?
    Y   N    
   [No further questions are required.]
  6. Does the patient have confirmed or suspected carcinoma of the prostate or breast?
    Y   N    
  7. 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 9]
  8. 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 skip to question 10]
  9. 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 less than 5 ng/dL) or absence of endogenous testosterone?
    Y   N    
   [No further questions are required.]
  10. Is the patient being treated for delayed puberty?
    Y   N    
  11. Will the patient have bone development checked at least every 6 months?
    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