01/04/2012 <%PANumber%>
MEDIGOLD (MEDICARE) 1307
Avinza Extended Release PL (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 Avinza Extended Release PL (Medicare Prior Auth).
Drug Name (select from list of drugs shown)
Avinza ER Capsules (morphine extended release)
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 physician determined the participant to have moderate to severe pain?
    Y   N    
  2. Is the participant being prescribed extended release morphine for continuous, around-the-clock pain relief?
    Y   N    
  3. Has the member been assessed for clinical risks of opioid/substance abuse/or addiction by one of the following tools, or another assessment tool for opioid abuse: Screener and Opioid Assessment for Patients with Pain (SOAPP 1.0), Screener and Opioid Assessment for Patients with Pain, Revision (SOAPP-R), Opioid Risk Tool (ORT), Current Opioid Misuse Measure (COMM), The Diagnosis, Intractability, Risk, and Efficacy Score (DIRE)?
    Y   N    
  4. Is the request for Avinza?
    Y   N    
   [If the answer to this question is no, then skip to question 7.]
  5. Is the drug being dosed more often than every 24 hours?
    Y   N    
  6. Does the total daily dose of Avinza exceed 1600 mg?
    Y   N    
   [No further questions are required.]
  7. Is the drug being requested MS Contin, Oramorph SR, or Extended Release Morphine?
    Y   N    
   [If the answer to this question is no, then skip to question 9.]
  8. Is the drug being dosed more often than every 8 hours?
    Y   N    
   [No further questions are required.]
  9. Is the request for Kadian?
    Y   N    
   [If the answer to this question is no, then skip to question 11.]
  10. Is the drug being dosed more often than every 12 hours?
    Y   N    
   [No further questions are required.]
  11. Is the request for Embeda?
    Y   N    
   [If the answer to this question is no, then no more questions are required.]
  12. Is the drug being dosed more often than every 12 hours?
    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