01/04/2012 <%PANumber%>
MEDIGOLD (MEDICARE) 1307
Elidel (Medicare Prior Authorization)

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 Elidel (Medicare Prior Authorization).
Drug Name (select from list of drugs shown)
Elidel (pimecrolimus)
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 2 years of age or older?
    Y   N    
   [If the answer to this question is no, then no further questions required.]
  2. Does the patient have the diagnosis of mild to moderate atopic dermatitis (eczema)?
    Y   N    
   [If the answer to this question is no, then no further questions required.]
  3. Has the patient completed a documented trial and failure of at least one medium or higher potency topical steroid?
    Y   N    
   [If the answer to this question is yes, then skip to question 5.]
  4. Does the patient have a documented intolerance or unresponsiveness to medium or higher potency topical steroids?
    Y   N    
  5. Has the patient been advised that Elidel should only be used to treat the immediate problem and then should be stopped when the condition improves?
    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