01/04/2012 <%PANumber%>
MEDIGOLD (MEDICARE) 1307
Byetta (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 Byetta (Medicare Prior Auth).
Drug Name (select from list of drugs shown)
Byetta (exenatide)
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 patient have a diagnosis of type 2 diabetes mellitus?
    Y   N    
   [If the answer to this question is no, then no further questions are required.]
  2. Has the patient been receiving Byetta therapy for at least 3 months?
    Y   N    
   [If the answer to this question is no, then skip to question 4.]
  3. Has the patient demonstrated a reduction in HbA1c since initiating Byetta therapy?
    Y   N    
   [If the answer to this question is yes, then skip to question 6.]
   [If the answer to this question is no, then no further questions are required.]
  4. Does the patient have an HbA1c level greater than 7 percent?
    Y   N    
   [If the answer to this question is no, then no further questions are required.]
  5. Has the patient demonstrated an inadequate treatment response, contraindication or been intolerant to metformin or a sulfonylurea?
    Y   N    
   [If the answer to this question is no, then no further questions are required.]
  6. Does the patient have a creatinine clearance of greater than 30mL per minute or normal kidney function?
    Y   N    
   [If the answer to this question is no, then no further questions are required.]
  7. Does the patient have a history of pancreatitis?
    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