Prior Authorization Criteria Form

02/26/2015
Prior Authorization Form
CHRISTUS Health Plan (Medicaid)
Januvia 25mg (Medicaid)
This fax machine is located in a secure location as required by HIPAA regulations.
Complete/review information, sign and date. Fax signed forms to CVS/Caremark at 1-866-255-7569.
Please contact CVS/Caremark at 1-855-656-0363 with questions regarding the prior authorization process.
When conditions are met, we will authorize the coverage of Januvia 25mg (Medicaid).
Drug Name (select from list of drugs shown)
Januvia 25mg
Patient Information
Patient Name:
Patient ID:
Patient Group No.:
Patient DOB:
Patient Phone:
Prescribing Physician
Physician Name:
Physician Phone:
Physician Fax:
Physician Address:
City, State, Zip:
Diagnosis:
ICD Code:
Please circle the appropriate answer for each question.
1.
Is the patient 18 years of age or older?
Y N
[If the answer to this question is no, then no further questions required.]
2.
Does the patient have a diagnosis of type II diabetes in the past
730 days?
Y N
[If the answer to this question is no, then no further questions required.]
3.
Does the patient require one tablet per day or less?
Y N
Comments:
I affirm that the information given on this form is true and accurate as of this date.
Prescriber (Or Authorized) Signature and Date