01/04/2012 <%PANumber%>
MEDIGOLD (MEDICARE) 1307
Colistimethate Solution (Medicare B vs. D)

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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 Colistimethate Solution (Medicare B vs. D).
Drug Name (select from list of drugs shown)
Colistimethate
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 reside in one of the following long-term care (LTC) facilities?
    Y   N    
   A nursing home that is dually-certified as both a Medicare SNF and a Medicaid nursing facility (NF) \ A Medicaid-only NF that primarily furnishes skilled care \ A non-participating nursing home (i.e. neither Medicare nor Medicaid) that provides primarily skilled care \ An institution which has a distinct part SNF and which also primarily furnishes skilled care
   [If the answer to this question is no, then go to question 3.]
  2. Is Medicare Part A paying for the LTC facility bed during the days this treatment is being requested?
    Y   N    
   [No further questions required.]
  3. Is the inhalation solution being administered through a Medicare covered nebulizer (Medicare covered DME device)?
    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