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

Kuvan Passport - Prior Authorization Request Form Page 2

14. Is this request for second re-authorization for PKU?  Yes  No

15. 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?

 Yes  No If No, skip to #17

16. Did the patient experience a reduction in blood Phe level (taken after the dose increase) less than 20% from

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

17. Has the patient’s current blood Phe level from at least 30 days of the request been obtained?  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 sponsor.

X_______________________________________________________________________

Prescriber or Authorized Signature

Date (mm/dd/yy)

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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