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

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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 Exjade (Medicare Prior Authorization).
Drug Name (select from list of drugs shown)
Exjade (deferasirox)
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 at least two years of age?
    Y   N    
   [If no, no further questions.]
  2. Does the patient have a diagnosis of transfusion-dependent anemia?
    Y   N    
   [If no, no further questions.]
  3. Does the patient have chronic iron overload due to blood transfusions (transfusional hemosiderosis)?
    Y   N    
   [If no, no further questions.]
  4. Is Exjade prescribed by or in consultation with a hematologist?
    Y   N    
   [If no, no further questions.]
  5. Is the creatinine clearance less than 40 mL/min or evidence of overt proteinuria?
    Y   N    
   [If yes, no further questions.]
  6. Is the patient’s platelet count less than 50 x 1,000,000,000 per liter?
    Y   N    
   [If yes, no further questions.]
  7. Does the patient have high-risk myelodysplastic syndrome (MDS) with poor performance status?
    Y   N    
   [If yes, no further questions.]
  8. Does the patient have an advanced malignancy?
    Y   N    
   [If yes, no further questions.]
  9. Will Exjade be used concurrently with Desferal (deferoxamine) or iron-containing products?
    Y   N    
   [If yes, no further questions.]
  10. Is the patient currently receiving Exjade therapy?
    Y   N    
   [If yes, skip to question 12.]
  11. Does the patient have pretreatment serum ferritin level within the last 60 days of at least 1000 mcg/L?
    Y   N    
   [If yes, skip to question 14.]
   [If no, no further questions.]
  12. Does the patient have serum ferritin level less than 500 mcg/L?
    Y   N    
   [If no, skip to question 14.]
  13. Will the prescriber consider temporarily interrupting therapy with Exjade?
    Y   N    
   [If no, no further questions.]
  14. Will the following labs be monitored at baseline and monthly for the duration of therapy?
    Y   N    
   Serum ferritin/ Serum creatinine/creatinine clearance/ Serum transaminases/ Bilirubin

Comments:  

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

 
Prescriber (Or Authorized) Signature and Date