Inhalation Solutions-Beta 2 Agonists, Anticholinergics, Corticosteroids

Prior Authorization Prescriber Fax Form

Inhalation Solutions-Beta 2 Agonists, Anticholinergics, Corticosteroids, Mast Cell Stabilizers (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 1-800-294-5979 with questions regarding the prior authorization process. When conditions are met, we will authorize the coverage of Inhalation Solutions-Beta 2 Agonists, Anticholinergics, Corticosteroids, Mast Cell Stabilizers (Coverage Determination).

Drug Name (Enter requested drug below) Albuterol inhalation solution/Accuneb (albuterol), Brovana (arformoterol tartrate), Cromolyn Inhalation Soln (cromolyn sodium), Duoneb (ipratropium/albuterol), Ipratropium Inhalation Soln (ipratropium bromide), Perforomist (formoterol), Pulmicort (budesonide), Xopenex (levalbuterol)

Patient Information Patient Name: Patient ID: Patient Phone 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 reside in one of the following long-term Y N 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 the answer to this question is no, skip to question 3.] 2. Is Medicare Part A paying for the LTC facility bed during the Y N days this treatment is being requested? [No further questions required.] 3. Is the patient using the medication with a nebulizer? Y N

[If the answer to this question is no, no further questions required.] 4. Does the patient require albuterol, arformoterol, Y N budesonide, cromolyn, formoterol, ipratropium, ipratropium/albuterol, or levalbuterol for the management of asthma or obstructive pulmonary disease (ICD-9 diagnosis codes 491.0–508.9)?

Comments:

I affirm that the information given on this form is true and accurate as of this date.

Prescriber (Or Authorized) Signature and Date