01/04/2012 <%PANumber%>
MEDIGOLD (MEDICARE) 1307
Arcalyst (Medicare Determination)

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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 Arcalyst (Medicare Determination).
Drug Name (select from list of drugs shown)
Arcalyst (rilonacept)
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 physician purchasing and providing the drug “incident to” physician services (i.e., drugs supplied and administered by a physician or under a physician’s direct supervision)?
    Y   N    
   [If the answer to this question is yes, then no further questions required.]
  2. Is the patient in a long-term care (LTC) bed that is covered by Medicare?
    Y   N    
  3. Is the request for one of the following drugs via an IV infusion pump?
    Y   N    
   Acyclovir \ Foscamet \ Amphotericin B \ Fluorouracil \ Cytarabine \ Bleomycin \ Doxorubicin \ Vincristine \ Vinblastine \ Treprostinil (Remodulin) \ Cisplatin \ Gemcitabine \ Oxaliplatin / Morphine
  4. Does the patient have the diagnosis of cryopyrin-associated periodic syndromes (CAPS) including:
    Y   N    
   Familial Cold Auto-Inflammatory Syndrome (FCAS) \ Muckle-Wells Syndrome (MWS)
   [If no, no further questions.]
  5. Is the patient greater than or equal to 12 years of age?
    Y   N    
   [If no, no further questions.]
  6. Does the patient have an active or chronic infection?
    Y   N    
   [If yes, no further questions.]
  7. Will Arcalyst be used in combination with another biologic agent?
    Y   N    
   If yes, no further questions.]
  8. Is the patient currently receiving Arcalyst therapy?
    Y   N    
   [If no, no further questions.]
  9. Has the patient responded to Arcalyst therapy (e.g., condition improved or stabilized)?
    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