01/04/2012 <%PANumber%>
MEDIGOLD (MEDICARE) 1307
Bone/Mineral Metabolism Agents (Medicare B vs D)

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 Bone/Mineral Metabolism Agents (Medicare B vs D).
Drug Name (specify drug)
    
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. Does the prescriber (i.e., nephrologist, nurse practitioner, or physician assistant) receive a monthly capitation payment to manage the end stage renal disease (ESRD) patients’ care?
    Y   N    
   [If the answer to this question is no, then no further questions required.]
  2. Is the drug prescribed to be used for an ESRD-related condition?
    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