Ivig Passport - Prior Authorization Request Form printable pdf download

IVIG

Passport - 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 1-844-802-1404. If you have questions

regarding the prior authorization, please contact CVS Caremark at 1-844-380-8830. 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: ___________________

Request Initiated For: _______________________

What drug is being prescribed?

 Bivigam  Flebogamma  Gammagard Liquid  Gammagard S-D  Gammaplex  Gamunex

 Gamunex-C  Hizentra  Privigen  Other __________________________

Is the requested medication intended to be processed under Home Infusion or Medical?  Yes  No

NOTE: If Yes, please route to Passport UM fax: 502-585-7989

What is the patient's diagnosis/reason for treatment?

 Primary immunodeficiency state in patient who is unable to produce sufficiency amounts of IgG antibodies (e.g.,

congenital agammaglobulinemia, X-linked agammaglobulinemia)

 Common variable hypogammaglobulinemia

 X-linked immunodeficiency with/without hyper IgM

 Wiskott-Aldrich syndrome

 Severe combined immunodeficiency

 Prevention of bacterial infections in patients with hypogammaglobulinemia

 Recurrent bacterial infections associated with B cell chronic lymphocystic leukemia

 Hemolytic anemia

 Kawasaki syndrome

 HIV

 Bone marrow transplant

 Parvovirus B19 infections, chronic and severe anemia associated with bone marrow suppression

 Severe eczema in patient who have hyperimmunoglobulinemia E syndrome and atopic dermatitis

 Lambert-Eaton myasthenic syndrome or an acute exacerbation of myasthenia gravis (not for chronic maintenance

therapy) or stabilization pre-operatively for myasthenia gravis patient

 Multiple sclerosis

  Immune thrombocytopenia purpura (ITP)

  Humoral or vascular allograft rejection

 Autoimmune mucocutaneous blistering diseases

  Prevention or as an adjunct treatment of infections in high-risk preterm low birth weight neonates

 Post-transfusion purpura

  Guillain-Barre syndrome

  Chronic inflammatory demyelinating polyneuropathy

 Other _____________________________________________

Send completed form to: Case Review Unit, CVS Caremark Prior Authorization 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. IVIG Passport - 4/2017.

CVS Caremark Prior Authorization ● 2211 Sanders Road NBT-6 ● Northbrook, IL 60062

Phone: 1-866-814-5506 ● Fax: 1-866-249-6155 ●

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