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

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 Buprenorphine (Medicare Prior Auth).
Drug Name (select from list of drugs shown)
Buprenorphine
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 drug being requested Subutex (buprenorphine)?
    Y   N    
   [If the answer to this question is no, skip to question 3.]
  2. Is the patient a pregnant female?
    Y   N    
  3. Has the patient been receiving Suboxone or Subutex (buprenorphine)?
    Y   N    
   [If the answer to this question is no, skip to question 6.]
  4. Has the prescriber documented that the patient is not receiving other opioids?
    Y   N    
  5. Will the patient be monitored periodically (e.g., random urine drug screen, assessment of patient’s progress (e.g., relapse, progress/accomplishment of treatment goals))?
    Y   N    
  6. Is the patient 16 years of age or older?
    Y   N    
  7. Does the patient have the diagnosis of opioid dependence?
    Y   N    
  8. Is the prescriber certified through CSAT (The Center for Substance Abuse Treatment) of SAMHSA (Substance Abuse and Medical Health Services Administration) to prescribe Suboxone and Subutex (buprenorphine)? (If yes, please provide registration number at the end of form)
    Y   N    
  9. Is the prescription part of an overall treatment program?
    Y   N    
   (e.g., self-help groups, counseling, vocational training)


  10. If yes, provide registration number
   
 

Comments:  

I affirm that the information given on this form is true and accurate as of this date.

 
Prescriber (Or Authorized) Signature and Date