Download BYDUREON_2015 PA FAX_796-A_V1 120114

Prescriber Fax Form
MediGold
Bydureon (exenatide extended-release)
(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 Bydureon (exenatide extendedrelease) (Coverage Determination).
Drug Name (select from list of drugs shown):
Bydureon (exenatide extended-release)
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.
Has the patient been receiving GLP-1 Agonist therapy for at least 3
months?
Yes
No
Yes
No
Yes
No
[Note: Examples of GLP-1 Agonists are Bydureon, Byetta, Victoza]
[If the answer to this question is no, skip to question 3.]
2.
Has the patient demonstrated an expected reduction in HbA1c since
starting GLP-1 Agonist therapy?
[No further questions are required.]
3.
Does the patient have any contraindications or precautions to
Bydureon?
- Personal or family history of medullary thyroid carcinoma (MTC)
- Multiple Endocrine Neoplasia syndrome type 2 (MEN 2)
- History of pancreatitis
- Severe renal impairment (creatinine clearance less than 30mL per
minute)
- End stage renal disease
4.
Does the patient have a diagnosis of type 2 diabetes mellitus?
Yes
No
5.
Does the patient have an HbA1c level above 7 percent AND has
demonstrated an inadequate treatment response, contraindication
or intolerance to metformin OR a sulfonylurea OR a
thiazolidinedione?
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