01/04/2012 <%PANumber%>
MEDIGOLD (MEDICARE) 1307
Cyclophosphamide (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 Cyclophosphamide (Medicare B vs. D).
Drug Name (select from list of drugs shown)
Cyclophosphamide tablets
Patient Information
Patient Name:    
Patient ID:    
Patient Group No.:    
Patient DOB:    
Prescribing Physician
Physician Name:    
Physician Phone:    
Physician Fax:    
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Diagnosis:     ICD Code:  
Please circle the appropriate answer for each question.
  1. Is this drug being used as treatment for cancer?
    Y   N    
   [If the answer to this question is no, then no further questions are required.]
  2. Is the oral formulation used for the same indication(s) as the formulation that cannot be self-administered?
    Y   N    
   [If the answer to this question is no, then no further questions are required.]
  3. Will the oral formulation be used as a full replacement for the formulation that cannot be self-administered?
    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