01/04/2012 <%PANumber%>
MEDIGOLD (MEDICARE) 1307
Chantix (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 Chantix (Medicare Prior Authorization).
Drug Name (select from list of drugs shown)
Chantix (varenicline)
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 require treatment for tobacco cessation?
    Y   N    
  2. Is the patient currently taking branded Zyban?
    Y   N    
   [If the answer to this question is no, then skip to question 4.]
  3. Will branded Zyban be discontinued while patient is taking Chantix?
    Y   N    
  4. Is the patient currently taking Chantix?
    Y   N    
   [If the answer to this question is no, then skip to question 6.]
  5. Has the patient’s treatment, including the use of Chantix, resulted in tobacco cessation?
    Y   N    
  6. Will the patient be observed for neuropsychiatric symptoms including changes in behavior, hostility, agitation, depressed mood, and suicide related events, including ideation, behavior, and attempted suicide while taking Chantix?
    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