01/04/2012 <%PANumber%>
MEDIGOLD (MEDICARE) 1307
Dronabinol (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 Dronabinol (Medicare Prior Auth).
Drug Name (select from list of drugs shown)
Dronabinol
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 have the diagnosis of anorexia associated with weight loss in AIDS?
    Y   N    
   [If the answer to this question is no, skip to question 7.]
  2. Has the patient had an involuntary weight loss of greater than 10 percent of pre-illness baseline body weight or body mass index (BMI) less than 20 kg per square meter in the absence of a concurrent illness or medical condition other than Human Immunodeficiency Virus (HIV) infection that may cause weight loss?
    Y   N    
   [If the answer to this question is no, no further questions required.]
  3. Has the patient demonstrated an inadequate treatment response to a 30-day drug regimen of megestrol acetate (Megace)?
    Y   N    
   [If the answer to this question is yes, skip to question 5.]
  4. Does the patient have a contraindication to or been intolerant to megestrol acetate (Megace)?
    Y   N    
   [If the answer to this question is no, no further questions required.]
  5. Has the patient previously received Marinol therapy?
    Y   N    
   [If the answer to this question is no, no further questions.]
  6. Has the patient demonstrated a positive response to Marinol therapy by maintaining or increasing his initial weight and/or muscle mass?
    Y   N    
   [No further questions required.]
  7. Does the patient have a diagnosis of nausea and vomiting associated with cancer chemotherapy?
    Y   N    
   [If the answer to this question is no, no further questions required.]
  8. Is the patient receiving a chemotherapy or radiation regimen?
    Y   N    
   [If the answer to this question is no, no further questions required.]
  9. Has the patient, through at least one cycle of chemotherapy, experienced an inadequate treatment response to or intolerance to intravenous Zofran and at least one of the following anti-emetic agents: metoclopramide, promethazine, prochlorperazine, meclizine, trimethobenzamide, or oral 5-HT3 receptor antagonists (e.g. Zofran, Kytril)?
    Y   N    
   [If the answer to this question is no, no further questions required.]
  10. Has the patient received previous Marinol therapy?
    Y   N    
   [If the answer to this question is no, no further questions.]
  11. Has the patient shown a positive response to Marinol therapy by showing a reduced incidence of emesis and/or nausea?
    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