01/04/2012 <%PANumber%>
MEDIGOLD (MEDICARE) 1307
Cayston (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 Cayston (Medicare Prior Auth).
Drug Name (select from list of drugs shown)
Cayston (aztreonam)
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 diagnosis of CF been confirmed by appropriate diagnostic or genetic testing?
    Y   N    
   [If no, then no further questions.]
  2. Is Pseudomonas aeruginosa present in the cultures of the airway?
    Y   N    
   [If no, then no further questions.]
  3. Is the patient currently receiving Cayston?
    Y   N    
   [If no, then no further questions.]
  4. Is the patient younger than 6 years of age?
    Y   N    
   [If yes, then skip to question 6.]
  5. Has the patient's lung function worsened while on Cayston (defined as a decrease in PFTs by greater than 10%)?
    Y   N    
   [If no, then no further questions.]
  6. Is there a clinical reason to continue Cayston therapy (e.g., patient had symptomatic improvement, patient had decreased number of pulmonary infections and/or exacerbations)?
    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