MediGold
Signifor (pasireotide)
(Coverage Determination)
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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 Signifor (pasireotide) (Coverage Determination).
Drug Name:
Signifor (pasireotide)
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 Cushing’s disease?
[If no, no further questions.] / Yes / No
2. / Did the patient have surgery that was not curative?
[If yes, skip to question #4.] / Yes / No
3. / Is the patient a candidate for surgery?
[If yes, no further questions.] / Yes / No
4. / Is Signifor prescribed by or in consultation with an endocrinologist?
[If no, no further questions.] / Yes / No
5. / Is the patient currently receiving Signifor therapy?
[If no, skip to question #7.] / Yes / No
6. / Has the patient shown a clinically meaningful reduction in 24-hour urinary free cortisol levels and/or improvement in signs or symptoms of the disease?
[If no, no further questions.]
[If yes, skip to question #8.] / Yes / No
7. / Prior to starting Signifor therapy, have baseline fasting plasma glucose and/or hemoglobin A1c levels been obtained?
[If no, no further questions.] / Yes / No
8. / Does the patient have controlled blood glucose levels?
[If yes, no further questions.] / Yes / No
9. / Is the patient receiving optimized antidiabetic therapy? / 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