Serostim

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 diagnosis? q HIV-associated wasting/cachexia q Other ______

2. What is the ICD-10 code? ______

3. Is Serostim prescribed by, or in consultation with, an infectious disease specialist? q Yes q No

4. Is the patient on anti-retroviral therapy? q Yes q No

5. Does the patient have active malignancy or history of malignancy in the past 12 months? q Yes q No

6. Document the following for both pretreatment AND current (if on therapy):

Height PRETREATMENT: ______feet ______inches CURRENT: ______feet ______inches

Weight PRETREATMENT: ______lbs / kg CURRENT: ______lbs / kg (circle units)

BMI PRETREATMENT: ______kg/m2 CURRENT: ______kg/m2

7. Is the patient currently on Serostim therapy through a CVS/Caremark administered benefit?

q Yes q No If No, skip to #9

8. Did the patient’s BMI improve or stabilize in response to Serostim therapy? q Yes q No

9. Has the patient tried and had a suboptimal response to alternative therapies?

If Yes, indicate below and skip #11 to or mark "None of the above".

q Marinol (dronabinol) q Testosterone therapy if hypogonadal

q Megace (megestrol) q Other ______
q Cyproheptadine q None of the above

10. If none of the above, did the patient have a contraindication or intolerance to alternative therapies? q Yes q No

11. Prior to initiating therapy with Serostim, did the patient experience unintentional weight loss greater than 5% of body weight in the previous 6 months? q Yes q No

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. Serostim SGM - 8/2016.

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

Page 1 of 1