Prior Authorization Form - Medicare Administrative Prior Authorization For Part B/d Coverage Page 2

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IMMUNOSUPPRESSANTS
(Please circle drug): Cellcept®, Imuran®, cyclosporine (Neoral®, Sandimmune®, Gengraf®), Rapamune®, Prograf®,
Myfortic®, Other: ___________________________
Diagnosis and diagnosis code: __________________________
All of the following questions must be answered for patients who underwent transplantation for requests to be processed:
1) Transplanted organ: (specify)_________________________________________
2) Date of transplant: _________________________________________
3) Was transplant received by Medicare-approved facility?
Yes
No
4) Was patient eligible for Medicare part A coverage at the time of the
Yes
No
transplant?
END STAGE RENAL DISEASE (ESRD) MEDICATION
(Please circle drug): Aranesp®, Epogen®, Procrit®, Activase®, Calcitriol, Calcium gluconate, Carnitor®, Cetacaine® medical kit,
Desferal®, Hectoral®, Heparin 1,000 units/ml vial, Levocarnitine, Lido/Prilocaine (Emla®), Pre-attached LTA kit (lidocaine
soln 4%), Protamine, Refludan® 50mg vial, Retacvase®, Rocaltrol®, Synera®Patch, Vibativ® and Zemplar®
Is the member ON dialysis?
Yes
No
Is requested medication being used for a diagnosis related to dialysis?
Yes
No
If no, (provide diagnosis and details):
_____________________________________________________________________________
Requesting physician’s specialty: __________________________________________________________
Please add any other supporting medical information that may be useful in the decision making process:
____________________________________________________________________________________________________
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FAX: (888) 671-5285 or EMAIL:
YOUR OFFICE WILL RECEIVE A RESPONSE VIA FAX OR MAIL
07/2015 PA019-Medicare B vs. D
Provider Communication

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