01/04/2012 <%PANumber%>
MEDIGOLD (MEDICARE) 1307
Celebrex (Medicare Prior Authorization)

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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 Celebrex (Medicare Prior Authorization).
Drug Name (select from list of drugs shown)
Celebrex 400mg (celecoxib)
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 patient being treated for post-operative pain following CABG surgery?
    Y   N    
  2. Does the patient have a diagnosis of juvenile rheumatoid arthritis (JRA), also referred to as juvenile idiopathic arthritis (JIA)?
    Y   N    
   [If answer to this question is yes, then no further questions are required.]
  3. Does the patient have a diagnosis of primary dysmenorrhea?
    Y   N    
   [If answer is to this question is yes, then no further questions are required.]
  4. Does the patient have a diagnosis of osteoarthritis?
    Y   N    
   [If answer to this question is yes, then no further questions are required.]
  5. Does the patient have a diagnosis of inflammatory arthritis (e.g., rheumatoid, ankylosing spondylitis, etc)?
    Y   N    
   [If answer to this question is yes, then no further questions are required.]
  6. Does the patient have a diagnosis of acute pain?
    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