01/04/2012 <%PANumber%>
MEDIGOLD (MEDICARE) 1307
Campral (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 Campral (Medicare Prior Auth).
Drug Name (select from list of drugs shown)
Campral (acamprosate calcium)
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 member have a clinical diagnosis of alcohol dependence?
    Y   N    
   [If the answer to this question is no, then no further questions required.]
  2. Does clinical evidence indicate that the member will abstain from alcohol consumption for at least 5 days prior to treatment initiation?
    Y   N    
   [If the answer to this question is no, then no further questions required.]
  3. Does the member have a diagnosis of renal failure?
    Y   N    
   [If the answer to this question is yes, then no further questions required.]
  4. Has the member had an inadequate treatment response to a trial of oral or injectable naltrexone at clinically significant dosage and duration?
    Y   N    
   [If the answer to this question is yes, skip to question 6.]
  5. Has therapy with naltrexone been documented to be inappropriate for this member for reasons such as hepatic insufficiency or chronic pain medication use?
    Y   N    
  6. Will Campral administration be a part of a comprehensive psychosocial treatment program for this member?
    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