01/04/2012 <%PANumber%>
MEDIGOLD (MEDICARE) 1307
Cubicin (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 Cubicin (Medicare B vs. D).
Drug Name (select from list of drugs shown)
Cubicin (daptomycin) Daptomycin
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 patient receiving dialysis services?
    Y   N    
   [If the answer to this question is no, then go to question 3.]
  2. Is daptomycin or IV vancomycin being used to treat an access site infection?
    Y   N    
   [If the answer to this question is yes, then no further questions required.]
  3. 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.]
  4. Is the patient in a long-term care (LTC) bed that is covered by Medicare?
    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