Temodar
Prior Authorization Request
CVS Caremark administers the prescription benefit plan for the patient identified. This patient’s benefit plan requires prior authorization for certain medications in order for the drug to be covered. To make an appropriate determination, providing the most accurate diagnosis for the use of the prescribed medication is necessary. Please respond below and fax this form to CVS Caremark toll-free at 1-866-249-6155. If you have questions regarding the prior authorization, please contact CVS Caremark at 1-866-814-5506. For inquiries or questions related to the patient’s eligibility, drug copay or medication delivery; please contact the Specialty Customer Care Team: CaremarkConnect® 1-800-237-2767.
Patient’s Name: ______Date: ______
Patient’s ID: ______Patient’s Date of Birth: ______
Physician’s Name: ______
Specialty: ______NPI#: ______
Physician Office Telephone: ______Physician Office Fax: ______
1. What is the patient’s diagnosis?
q Central nervous system (CNS) cancer q Pancreatic neuroendocrine tumors
q Soft tissue sarcoma q Melanoma
q Ewing’s sarcoma q Mycosis fungoides/Sézary syndrome (MF/SS)
q Uterine sarcoma q Dermatofibrosarcoma protuberans (DFSP)
q Lung neuroendocrine tumors q Small cell lung cancer
q Other ______
2. What is the ICD-10 code? ______
3. How is the patient's disease classified? Please check all that apply.
q Progressive q Metastatic
q Recurrent q Unresectable
q None of the above
4. Is Temodar being used as a single agent? If Yes, skip to diagnosis section. q Yes q No
5. Is Temodar being used in combination with one of the following medications?
Indicate below or mark "None of the above."
q bevacizumab (Avastin) q irinotecan (Camptosar)
q rituximab (Rituxan) q capecitabine (Xeloda)
q None of the above
Complete the following section based on the patient's diagnosis.
Section A: CNS Cancer
6. What type of CNS cancer is being treated?
q Glioblastoma q Supratentorial primitive neuroectodermal tumor (PNET)
q Medulloblastoma q Intracranial or spinal ependymoma
q Anaplastic glioma q Brain metastases
q CNS lymphoma q Supratentorial astrocytoma/oligodendroglioma
q Other ______
7. If patient has glioblastoma or anaplastic glioma cancer type, what is the intent of treatment?
q Maintenance treatment q Recurrent/salvage treatment q Adjuvant treatment
q Other ______
8. If patient has supratentorial primitive neuroectodermal tumor, is Temodar being prescribed as recurrence therapy in a patient who received prior chemotherapy? q Yes q No
Section B: Soft Tissue Sarcoma (STS)
9. What type of soft tissue sarcoma is being treated?
q Rhabdomyosarcoma q Solitary fibrous tumor q Sarcoma of the extremity/trunk
q Hemangiopericytoma q Angiosarcoma q Retroperitoneal/intra-abdominal soft tissue sarcoma
q Other ______
I attest that this information is accurate and true, and that documentation supporting this
information is available for review if requested by CVS Caremark or the benefit plan sponsor.
X______
Prescriber or Authorized Signature Date (mm/dd/yy)
Send completed form to: Case Review Unit CVS Caremark Specialty Programs Fax: 1-866-249-6155
Note: This fax may contain medical information that is privileged and confidential and is solely for the use of individuals named above. If you are not the intended recipient you hereby are advised that any dissemination, distribution, or copying of this communication is prohibited. If you have received the fax in error, please immediately notify the sender by telephone and destroy the original fax message. Temodar SGM - 2/2016.
CVS Caremark Specialty Pharmacy ● 2211 Sanders Road NBT-6 ● Northbrook, IL 60062
Phone: 1-866-814-5506 ● Fax: 1-866-249-6155 ● www.caremark.com
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