01/04/2012 <%PANumber%>
MEDIGOLD (MEDICARE) 1307
Colcrys Post Limit (Medicare Prior Auth)

This fax machine is located in a secure location as required by HIPAA regulations.
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 Colcrys Post Limit (Medicare Prior Auth).
Drug Name (select from list of drugs shown)
Colcrys (colchicine)
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 Colcrys being requested for the treatment of familial Mediterranean fever (FMF)?
    Y   N    
   [Note: Patients are allowed 60 tablets per month of Colcrys without prior authorization.]

Comments:  

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

 
Prescriber (Or Authorized) Signature and Date