01/04/2012 <%PANumber%>
MEDIGOLD (MEDICARE) 1307
Exalgo Post Limit (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 Exalgo Post Limit (Medicare Prior Auth).
Drug Name (select from list of drugs shown)
Exalgo 12mg (hydromorphone) Exalgo 16mg (hydromorphone)
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 require more than 32mg in a 24-hour period?
    Y   N    
   [Patients can receive up to 32mg/day (two 16mg tablets/day) without prior authorization.]
   [If the answer to this question is no, then no prior authorization is required.]
  2. Does the patient have impaired pulmonary function (e.g., significant respiratory depression, acute or severe bronchial asthma, hypercarbia)?
    Y   N    
  3. Does the patient have a diagnosed or suspected paralytic ileus?
    Y   N    
  4. Has the patient had a prior gastrointestinal (GI) surgical procedure and/or have underlying GI disease that has resulted in significant narrowing of the GI tract, “blind loops” of the GI tract or GI obstruction?
    Y   N    
  5. Does the patient have a known allergy to sulfite-containing medications?
    Y   N    
  6. Has the prescriber determined the patient to have persistent, moderate to severe chronic pain?
    Y   N    
   [If the answer to this question is no, then no further questions are required.]
  7. Does the patient require controlled-release hydromorphone tablets (Exalgo) for continuous, around-the-clock pain relief for an extended period of time?
    Y   N    
  8. Has the prescriber evaluated the patient’s risk for serious opioid adverse events (i.e., respiratory depression/sedation) before prescribing the requested long-acting opioid narcotic?
    Y   N    
  9. Will the patient or has the patient previously been assessed for clinical risks of opioid/substance abuse/or addiction by one of the following tools, or ANOTHER ASSESSMENT TOOL for opioid abuse: Screener and Opioid Assessment for Patients with Pain (SOAPP 1.0), Screener and Opioid Assessment for Patients with Pain, Revision (SOAPP-R), Opioid Risk Tool (ORT), Current Opioid Misuse Measure (COMM), The Diagnosis, Intractability, Risk, and Efficacy Score (DIRE)?
    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