01/04/2012 <%PANumber%>
MEDIGOLD (MEDICARE) 1307
Copaxone (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 Copaxone (Medicare Determination).
Drug Name (select from list of drugs shown)
Copaxone (glatiramer acetate)
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 \ Foscamet \ Amphotericin B \ Fluorouracil \ Cytarabine \ Bleomycin \ Doxorubicin \ Vincristine \ Vinblastine \ Treprostinil (Remodulin) \ Cisplatin \ Gemcitabine \ Oxaliplatin \ Morphine
  4. Does the patient have relapsing-remitting MS (RRMS)?
    Y   N    
   [If yes, skip to question 7.]
  5. Is Copaxone prescribed for the first clinical episode of MS?
    Y   N    
   [If no, no further questions.]
  6. Did the patient have an MRI scan that demonstrated features consistent with a diagnosis of MS (i.e., multifocal white matter disease)?
    Y   N    
   [If no, no further questions.]
  7. Will Copaxone be used concurrently with any of the following?
    Y   N    
   Intergeron beta therapy (Avonex, Betaseron, Extavia, or Rebif) \ Novantrone (mitoxantrone)
   [If yes, no further questions.]
  8. Has the patient been on Copaxone therapy for at least 12 months?
    Y   N    
   [If no, no further questions.]
  9. Has the patient demonstrated a clinical response to therapy, demonstrated by one of the following?
    Y   N    
   Decrease in the frequency of relapses \ Slowing of disease progression \ MRI lesions have diminished with therapy \ Patient is stable on therapy

Comments:  

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

 
Prescriber (Or Authorized) Signature and Date