Prescriber Fax Form
MediGold
Infusion Pump Drugs
(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 Infusion Pump Drugs
(Coverage Determination).
Drug Name:
Infusion Pump Drugs
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.
Is the requested drug being administered via an external infusion pump?
[If no, then no further questions required.]
Yes
No
2.
Is the requested drug being administered via an external infusion pump in
the home (e.g. PATIENT’S HOME, NOT A FACILITY)?
[If yes, then skip to question 6.]
Yes
No
3.
Does the patient reside in one of the following long-term care (LTC)
facilities:
A nursing home that is dually-certified as both a Medicare SNF and a
Medicaid nursing facility (NF), a Medicaid-only NF that primarily furnishes
skilled care, a non-participating nursing home (i.e. neither Medicare nor
Medicaid) that provides primarily skilled care, an institution which has a
distinct part SNF and which also primarily furnishes skilled care, or an
intermediate care facility for the mentally retarded (ICF/MR)?
[If no, then skip to question 5.]
Yes
No
4.
Is Medicare Part A paying for the LTC facility bed during the days this
treatment is being requested?
[No further questions required.]
Yes
No
5.
Is the drug being purchased AND administered by a physician (or by
personnel under direct supervision of a physician) during a physician’s
professional service (i.e., the drug is being furnished “incident to a
physician’s service”)?
[No further questions required.]
Yes
No
6.
Is the drug being prescribed a narcotic analgesic for a non-cancer
diagnosis?
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