Download Prescriber Fax Form MediGold Tarceva (erlotinib) (Coverage

Prescriber Fax Form
MediGold
Tarceva (erlotinib)
(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 Tarceva (erlotinib)
(Coverage Determination).
Drug Name (select from list of drugs shown):
Tarceva (erlotinib)
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 a diagnosis of non-small cell lung cancer?
[If no, skip to question #10.]
Yes
No
2.
Is the disease locally advanced, recurrent, or metastatic?
[If no, no further questions.]
Yes
No
3.
Will Tarceva be used as first-line treatment?
[If no, skip to question #6.]
Yes
No
4.
Has EGFR mutation testing been performed?
[If no, no further questions.]
Yes
No
5.
Does the patient have either exon 19 deletion or exon 21 (L858R)
substitution mutation?
[No further questions.]
Yes
No
6.
Will Tarceva be used maintenance treatment?
Yes
No
[If no, skip to question #8.]
7.
Did the patient respond to or remain stable after first-line chemotherapy?
[If yes, skip to question #9.]
[If no, no further questions.]
Yes
No
8.
Will Tarceva be used as second- or third-line treatment?
[If no, no further questions.]
Yes
No
9.
Will Tarceva be used as a single agent?
[No further questions.]
Yes
No
10. Does the patient have a diagnosis of pancreatic cancer?
[If no, skip to question #12.]
Yes
No
11. Does the patient meet ALL of the following criteria:
 Locally advanced, unresectable, or metastatic pancreatic cancer
 Tarceva will be used in combination with gemcitabine
[No further questions.]
Yes
No
12. Does the patient have a diagnosis of chordoma?
[If no, no further questions.]
Yes
No
13. Does the patient meet ALL of the following criteria:
 Chordoma is recurrent
 Tarceva will be used as monotherapy or in combination with
Erbitux (cetuximab)
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