Prescriber Fax Form
MediGold
Privigen (Intravenous Immune Globulin (Human) – IVIG)
(Coverage Determination)
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 Privigen (Intravenous Immune
Globulin (Human) – IVIG) (Coverage Determination).
Drug Name:
Privigen (Intravenous Immune Globulin (Human) – IVIG)
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.
Does the patient have any of the following contraindications to the use of
immune globulin?
 IgA deficiency with antibodies to IgA AND a history of hypersensitivity
 History of anaphylaxis or severe systemic reaction to the
administration of human immune globulin or product components
 Hyperprolinemia
[If yes, no further questions.]
Yes
No
2.
Does the patient have any of the following risk factors for acute renal
failure (ARF)?
 Pre-existing renal insufficiency
 Diabetes mellitus
 Age > 65
 Volume depletion
 Sepsis
 Paraproteinemia
 Receiving concomitant nephrotoxic drugs
[If yes, skip to question 4.]
Yes
No
3.
Does the patient have any of the following risk factors for thrombosis?
 Advanced age (45 years of age or older)
 Prolonged immobilization
 Hypercoagulable condition
 History of venous or arterial thrombosis
 Use of estrogens
 Indwelling central vascular catheter
 Hyperviscosity
 Cardiovascular risk factor(s)
[If no, skip to question 5.]
Yes
No
4.
Will the patient receive IVIG at the minimum dose or concentration
available and at the minimum rate of infusion practicable?
[If no, no further questions]
Yes
No
5.
Does the patient have a diagnosis of idiopathic thrombocytopenic purpura
(ITP)?
[If yes, no further questions.]
Yes
No
6.
Does the patient have a diagnosis of Kawasaki syndrome?
[If yes, no further questions.]
Yes
No
7.
Does the patient have a diagnosis of B-cell chronic lymphocytic leukemia
(CLL)?
[If no, skip to question 9.]
Yes
No
8.
Does the patient have hypogammaglobulinemia (serum IgG level <500
mg/dL) OR a history of recurrent bacterial infections?
[No further questions.]
Yes
No
9.
Does the patient have a diagnosis of chronic inflammatory demyelinating
polyneuropathy (CIDP)?
[If yes, no further questions.]
Yes
No
10. Does the patient have a diagnosis of multifocal motor neuropathy (MMN)?
[If yes, no further questions.]
Yes
No
11. Does the patient have a diagnosis of pure red cell aplasia (PRCA)
secondary to parvovirus B19 infection?
[If yes, no further questions.]
Yes
No
12. Does the patient have a diagnosis of myasthenia gravis?
[If yes, no further questions.]
Yes
No
13. Does the patient have a diagnosis of Lambert-Eaton myasthenic syndrome
(LEMS)?
[If yes, no further questions.]
Yes
No
14. Does the patient have a diagnosis of fetal/neonatal alloimmune idiopathic
thrombocytopenia (F/NAIT)?
[If yes, no further questions.]
Yes
No
15. Is the patient a bone marrow transplant/hematopoietic stem cell transplant
(BMT/HSCT) recipient?
[If no, skip to question 17.]
Yes
No
16. Does the patient have hypogammaglobulinemia (serum IgG level <400
mg/dL)?
[No further questions.]
Yes
No
17. Does the patient have a diagnosis of HIV?
[If no, skip to question 20.]
Yes
No
18. Is the patient 12 years of age or younger?
[If no, no further questions.]
Yes
No
19. Does the patient have hypogammaglobulinemia (serum IgG level <400
mg/dL) OR a history of recurrent bacterial infections?
[No further questions.]
Yes
No
20. Does the patient have a diagnosis of relapsing-remitting multiple sclerosis
(RRMS)?
[If no, skip to question 22.]
Yes
No
21. Is either of the following statements true?
 Standard first-line treatments (eg. interferon or glatiramer) have
been tried but were unsuccessful or not tolerated
 Patient is unable to receive standard first-line treatments (eg.
interferon or glatiramer) because of a contraindication or other
clinical reason
[No further questions.]
Yes
No
22. Does the patient have a diagnosis of Guillain-Barré syndrome (GBS)?
[If no, skip to question 25.]
Yes
No
23. Is physical mobility severely affected such that the patient requires an aid
to walk?
[If no, no further questions.]
Yes
No
24. Will immune globulin therapy be initiated within 2 weeks of symptom
onset?
[No further questions.]
Yes
No
25. Does the patient have a diagnosis of dermatomyositis?
[If yes, skip to question 27.]
Yes
No
26. Does the patient have a diagnosis of polymyositis?
[If no, no further questions.]
Yes
No
27. Is either of the following statements true?
 Standard first-line treatments (eg. corticosteroids or
immunosuppressants) have been tried but were unsuccessful or
not tolerated
 Patient is unable to receive standard first-line treatments (eg.
corticosteroids or immunosuppressants) because of a
contraindication or other clinical reason
[No further questions.]
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