Prescriber Fax Form
MediGold
Fentanyl Oral Intranasal Products
(Coverage Determination)
Abstral (fentanyl citrate sublingual tablet), Actiq (fentanyl citrate oral transmucosal lozenge), Fentora
(fentanyl citrate buccal tablet), Lazanda (fentanyl nasal spray), Onsolis (fentanyl citrate buccal soluble
film), Subsys (fentanyl sublingual spray)
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 1-855-633-7673.
Please contact CVS/Caremark at 1-866-785-5714 with questions regarding the prior authorization
process. When conditions are met, we will authorize the coverage of Fentanyl Oral Intranasal Products
(Coverage Determination).
Drug Name (select from list of drugs shown):
Patient Information
Patient Name:
Patient ID:
Patient Group No.:
Patient DOB:
Patient Phone:
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.
Will the oral/intranasal fentanyl product (e.g., Abstral, Actiq, Fentora,
Lazanda, Onsolis, or Subsys) be used to manage breakthrough pain due
to a current cancer condition or cancer related complication?
Yes
No
2.
Is a long-acting opioid being prescribed for around-the-clock treatment of
the cancer pain?
Yes
No
3.
Can the patient be safely started on the requested dose based on current
narcotic use history?
Yes
No
Comments:
I affirm that the information given on this form is true and accurate as of this date.
Prescriber (Or Authorized) Signature and Date