01/04/2012 <%PANumber%>
MEDIGOLD (MEDICARE) 1307
Azathioprine (Medicare B vs. D)

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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 Azathioprine (Medicare B vs. D).
Drug Name (select from list of drugs shown)
Azasan (azathioprine) Azathioprine
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 undergone an organ transplant?
    Y   N    
   [If the answer to this question is no, then no further questions are required.]
  2. Was the patient enrolled in Medicare Part A at the time of the transplant?
    Y   N    
   [If the answer to this question is no, then no further questions are required.]
  3. Is this drug part of an immunosuppressive regimen for an organ transplant?
    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