01/04/2012 <%PANumber%>
MEDIGOLD (MEDICARE) 1307
Emend 80mg or 125mg (Medicare B vs. D)

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When conditions are met, we will authorize the coverage of Emend 80mg or 125mg (Medicare B vs. D).
Drug Name (select from list of drugs shown)
Emend (aprepitant) 125mg Emend (aprepitant) 80mg Emend (aprepitant) 80mg & 125mg
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 Emend being requested because the patient has received chemotherapy?
    Y   N    
   [If the answer to this question is yes, skip to question 4.]
  2. Does the prescriber (i.e., nephrologist, nurse practitioner, or physician assistant) receive a monthly capitation payment to manage the end stage renal disease (ESRD) patients’ care?
    Y   N    
   [If the answer to this question is no, then no further questions required.]
  3. Is the drug prescribed to be used for an ESRD-related condition?
    Y   N    
   [No further questions required.]
  4. Did the patient have any IV antiemetic doses at the time of chemotherapy?
    Y   N    
   [If the answer to this question is yes, then no further questions are required.]
  5. Does the patient have the diagnosis of cancer?
    Y   N    
   [If the answer to this question is no, then no further questions are required.]
  6. Will this drug be part of a regimen that includes an oral corticosteroid (e.g., dexamethasone) and an oral 5-HT3-receptor antagonist (e.g., Zofran, Kytril, Anzemet)?
    Y   N    
   [If the answer to this question is no, then no further questions are required.]
  7. Is the patient receiving one or more of the following chemotherapeutic agents?
    Y   N    
   Carmustine \ Cisplatin \ Cyclophosphamide \ Dacarbazine \ Mechlorethamine \ Streptozocin \ Doxorubicin \ Epirubicin \ Lomustine

Comments:  

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

 
Prescriber (Or Authorized) Signature and Date