Prescriber Fax Form
MediGold
Botox (onabotulinumtoxinA)
(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 Botox (onabotulinumtoxinA)
(Coverage Determination).
Drug Name (select from list of drugs shown):
Botox (onabotulinumtoxinA)
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 Botox being prescribed for cosmetic purposes? (e.g., treatment of
wrinkles)
[If yes, no further questions.]
Yes
No
2.
Is Botox being prescribed for chronic migraine prophylaxis?
[If no, skip to question 7.]
Yes
No
3.
Is the request for continuation of therapy (after 1 injection cycle)?
[If yes, skip to question 6.]
Yes
No
4.
Does the patient experience at least 15 headache days per month?
[If no, no further questions.]
Yes
No
5.
Has the patient had an inadequate response to at least 8 weeks of oral
migraine preventative therapy?
[No further questions.]
Yes
No
6.
Has the patient achieved or maintained a 50% reduction in monthly
headache frequency since starting therapy?
Yes
No
[No further questions.]
7.
Does the patient have a diagnosis of blepharospasm?
[If yes, no further questions.]
Yes
No
8.
Does the patient have a diagnosis of strabismus?
[If yes, no further questions.]
Yes
No
9.
Does the patient have a diagnosis of cervical dystonia (e.g., torticollis)?
[If yes, no further questions.]
Yes
No
10. Does the patient have a diagnosis of primary axillary hyperhidrosis?
[If yes, no further questions.]
Yes
No
11. Does the patient have a diagnosis of upper limb spasticity?
[If yes, no further questions.]
Yes
No
12. Is Botox being prescribed for urinary incontinence associated with a
neurologic condition (e.g., spinal cord injury, multiple sclerosis) or with
overactive bladder?
[If no, skip to question 14.]
Yes
No
13. Has the patient had an inadequate response to or is intolerant of an
anticholinergic medication?
[No further questions.]
Yes
No
14. Does the patient have a diagnosis of excessive salivation secondary to
advanced Parkinson’s disease?
[If yes, no further questions.]
Yes
No
15. Does the patient have a diagnosis of hemifacial spasm?
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