Ivig Passport - Prior Authorization Request Form (Page 2 of 2) in pdf

What is the ICD-10 code? ________________

Is the requested medication being prescribed by a:  Hematologist  Oncologist  Allergist

 Primary care physician  Immunologist  Cardiologist  Infectious disease specialist

 Other _______________________________

Has the patient’s IgG levels been obtained?  Yes  No

Complete the following questions based on the patient's diagnosis/reason for treatment.

Section A: Hemolytic Anemia

Does the patient have hepatomegaly or hepatosplenomegaly?  Yes  No

Section B: Kawasaki Syndrome

Is the requested medication being used for the prevention of coronary aneurysms associated with the disease in

conjunction with high dose aspirin?  Yes  No

Section C: Multiple Sclerosis

Does the patient have impaired function measured by a standard clinical scale at the time of initial therapy?

 Yes  No

10. Is the patient refractory to other standard therapies (e.g., interferon) given in therapeutic doses over at least three

months, or is intolerant of, or has a contraindication to those standard therapies?  Yes  No

Section D: Immune Thrombocytopenia Purpura (ITP)

11. Has the patient’s platelet count been obtained?  Yes  No

Section E: Autoimmune Mucocutaneous Blistering Diseases

12. Does the patient have any of the following biopsy-proven conditions: pemphigus vulgaris, pemphigus foliaceus,

bullous pemphigoid, mucous membrane pemphigoid, or epidermolysis bullosa acquisita?  Yes  No

13. Has the patient failed conventional therapy (e.g., steroids) or conventional therapy is contraindicated?

 Yes  No

14. Does the patient have a rapidly progressive disease in which a clinical response could not be affected quickly

enough using conventional agents?  Yes  No If No, skip to #16

15. Will the requested medication be given along with conventional treatments and be used only until conventional

therapy could take affect?  Yes  No No further questions

16. Will the requested medication be used for the treatment of autoimmune mucocutaneous blistering disease for

short-term therapy and not as maintenance therapy?  Yes  No

Section F: Post-Transfusion Purpura, Guillain-Barre Syndrome, Chronic Inflammatory Demyelinating Polyneuropathy

17. Has the patient’s complete blood count been obtained?  Yes  No

18. Has the neurologist been consulted and the results of CT or MRI (brain or spinal cord) been obtained, if applicable?

 Yes  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 spons

or.

X_______________________________________________________________________

Prescriber or Authorized Signature

Date (mm/dd/yy)

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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