Kuvan Passport - Prior Authorization Request Form printable pdf download

Kuvan

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: ___________________

1. What is the patient's diagnosis?  Phenylketonuria (PKU)  Other _______________________

2. What is the ICD-10 code? ____________________

3. Has the patient’s current weight been obtained?  Yes  No

4. Is the patient currently utilizing a phenylalanine (Phe) restricted diet with Phe-free medical products or foods?

* NOTE: The documentation is consistent with order forms or receipts from no more than 30 days prior to the

request.  Yes  No

5. Is this request for an initial authorization for PKU?  Yes  No If No, skip to #8

6. Has the patient’s baseline blood Phe level from within 30 days of the request been obtained?  Yes  No

7. Is Kuvan being prescribed at a dose no greater than the FDA approved maximum initial dose of 10 mg per kg per

day and the treatment with Kuvan is being supervised by a physician knowledgeable in the management of children

and adults with PKU? If Yes, no further questions  Yes  No

8. Is Kuvan being prescribed at an FDA-approved dosage and supervised by a physician knowledgeable in the

management of children and adults with PKU?  Yes  No

9. Is this request for first re-authorization for PKU?  Yes  No If No, skip to #14

10. Are there at least two separate blood Phe levels?  Yes  No

11. Is this request for a dose increase to 20 mg per kg per day due to lack of response to the 10 mg per kg per day dose?

If Yes, skip to #13  Yes  No

12. Did the patient respond to treatment and obtain a 20% ore more reduction in the blood Phe level after one month of

treatment? If Yes, no further questions  Yes  No

13. Did the patient experience a reduction in blood phenylalanine level of at least 20% from baseline?

 Yes  No If No, no further questions

Send completed form to: Case Review Unit CVS Caremark Specialty Programs Fax: 1-844-802-1404

Note: This fax may contain medical information that is privileged and confidential and is solely for the use of individual s 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. Kuvan Passport - 9/2016.

CVS Caremark Specialty Pharmacy ● 2211 Sanders Road NBT-6 ● Northbrook, IL 60062

Phone: 1-844-380-8830 ● Fax: 1-844-802-1404 ●

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