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

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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 Gilenya (Medicare Prior Authorization).
Drug Name (select from list of drugs shown)
Gilenya (fingolimod)
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 have a relapsing form of multiple sclerosis?
    Y   N    
   [For example: relapsing-remitting MS, progressive-relapsing MS, or secondary progressive MS WITH relapses]
   [If no, no further questions.]
  2. Prior to initiating Gilenya therapy, has the patient had an inadequate response to a trial of an interferon beta agent (Avonex, Betaseron, Extavia, or Rebif) or glatiramer (Copaxone)?
    Y   N    
   [If yes, no further questions.]
  3. Did the patient have a contraindication to, or intolerance of, an interferon beta agent or Copaxone?
    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