01/04/2012 <%PANumber%>
MEDIGOLD (MEDICARE) 1307
Forteo (Medicare Determination)

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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 Forteo (Medicare Determination).
Drug Name (select from list of drugs shown)
Forteo (teriparatide)
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 physician purchasing and providing the drug “incident to” physician services (i.e., drugs supplied and administered by a physician or under a physician’s direct supervision)?
    Y   N    
   "Medicare Close as B: Drug should be covered under Medicare Part B. Please select the appropriate Close as B outcome."
   [If the answer to this question is yes, then no further questions required.]
  2. Is the patient in a long-term care (LTC) bed that is covered by Medicare?
    Y   N    
  3. Is the request for one of the following drugs via an IV infusion pump?
    Y   N    
   Acyclovir / Foscarnet / Amphotericin B / Flurouracil / Cytarabine / Bleomycin / Doxorubicin / Vincristine / Vinblastine / Treprostinil (Remodulin) / Cisplatin / Gemcitabine / Oxaliplatin / Morphine
  4. Does the patient have a diagnosis of:
    Y   N    
   Postmenopausal osteoporosis OR / Primary (idiopathic) or hypogonadal osteoporosis OR / Glucocorticoid-induced osteoporosis
   [If no, no further questions.]
  5. Does the patient have a history of osteoporotic fracture?
    Y   N    
   [If yes, skip to question 9.]
  6. Does the patient have greater than 1 risk factor for fracture?
    Y   N    
   Advanced age (postmenopausal women and men greater than 50 years of age) / Low body mass index (less than 19 kg/m2) / Parental history of hip fracture / Current smoking / Alcohol intake of 3 or more drinks per day / Glucocorticoid therapy (greater than or equal to 5 mg/day prednisone or equivalent for greater than or equal to 3 months) / Rheumatoid arthritis / Secondary causes of osteoporosis
   [If yes, skip to question 9.]
  7. Has the patient had an inadequate response to a bisphosphonate trial of a minimum of one year?
    Y   N    
   [If yes, skip to question 9.]
  8. Is a trial of a bisphosphonate contraindicated or was the patient intolerant to a trial of bisphosphonate therapy?
    Y   N    
   [If no, no further questions.]
  9. Does the patient have ANY of the following contraindications or exclusions to Forteo therapy?
    Y   N    
   Paget’s disease of bone / Unexplained elevations of alkaline phosphatase / Open epiphyses (ie, pediatric or young adult patient) / Prior radiation therapy involving the skeleton / History of a skeletal malignancy / Bone metastases / Pre-existing hypercalcemia / Metabolic bone disease other than osteoporosis
   [If yes, no further questions.]
  10. Has the patient been on Forteo therapy for less than 24 months and will Forteo be discontinued after a total of 24 months of treatment?
    Y   N    
   [If no, no further questions.]
  11. Will the patient be receiving bisphosphonate therapy concurrent with Forteo therapy?
    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