01/04/2012 <%PANumber%>
MEDIGOLD (MEDICARE) 1307
Cerezyme (Medicare Determination)

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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 Cerezyme (Medicare Determination).
Drug Name (select from list of drugs shown)
Cerezyme (imiglucerase)
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 physician purchasing and providing the drug “incident to” physician services (i.e., drugs supplied and administered by a physician or under a physician’s direct supervision)?
    Y   N    
   [If the answer to this question is yes, then no further questions required.]
  2. Is the patient in a long-term care (LTC) bed that is covered by Medicare?
    Y   N    
  3. Is the request for one of the following drugs via an IV infusion pump?
    Y   N    
   Acyclovir \ Foscarnet \ Amphotericin B \ Fluorouracil \ Cytarabine \ Bleomycin \ Doxorubicin \ Vincristine \ Vinblastine \ Treprostinil (Remodulin) \ Cisplatin \ Gemcitabine \ Oxaliplatin \ Morphine
  4. Does the patient have a diagnosis of Type 1 Gaucher disease?
    Y   N    
   [If no, then no further questions.]
  5. Was the diagnosis of Gaucher disease confirmed by any one of the following methods?
    Y   N    
   β-glucocerebrosidase enzyme assay (enzyme activity less than 30%) \ DNA testing \ Bone marrow histology
   [If no, then no further questions.]
  6. Is therapy initiated for the management of any one of the following conditions?
    Y   N    
   Anemia \ Thrombocytopenia \ Bone Disease \ Hepatomegaly \ Splenomegaly
   [If no, then no further questions.]
  7. Will Cerezyme/VPRIV be used in combination with Zavesca (miglustat)?
    Y   N    
   [If yes, then no further questions.]
  8. Has the patient received 24 months of enzyme replacement therapy?
    Y   N    
   [If no, then no further questions.]
  9. Has the patient experienced any of the following clinical improvements as a result of therapy?
    Y   N    
   Decreased liver and spleen volume \ Increased platelet count \ Increased hemoglobin concentration

Comments:  

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

 
Prescriber (Or Authorized) Signature and Date