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Prior Authorization Criteria Form

Prior Authorization Criteria Form CVS-CAREMARK FAX FORM 5-HT3 Antagonist Post Limit 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 1-888-836-0730. Please contact CVS|Caremark at 1-888-414-3125 with questions regarding the prior authorization process. When conditions are met, we will authorize the coverage of 5-HT3 Antagonist Post Limit.

Drug Name (select from list of drugs shown) Aloxi Anzemet Granisetron Kytril Ondansetron Sancuso Zofran Zuplenz

Patient Information Patient Name: Patient ID: Patient Group No.: Patient DOB: Prescribing Physician Physician Name: Physician Phone: Physician Fax: Physician Address: City, State, Zip: Diagnosis: 1. ICD Code:

Please circle the appropriate answer for each applicable question.

2. 3.

Does the participant require more than the following limits per 15 Y N days? Aloxi 0.25 mg/5 mL or 0.075mg/1.5 mL Injection - 5 mL Anzemet 50 mg and 100 mg Tablets - 3 tablets Anzemet 100 mg/5 mL or 12.5 mg/0.625 mL Injection - 5 mL Kytril 1 mg Tablets - 6 tablets Granisetron 1 mg/5 mL Oral Solution - 30 mL Kytril 0.1 mg/mL or 1 mg/mL Injection - 1 mL Sancuso 3.1 mg/24 hours Patches - 2 patches Zofran 4 mg and 8 mg Tablets/ODT - 12 tablets Ondansetron 24 mg Tablet - 1 tablet Zofran 4 mg/5 mL Oral Solution - 100 mL Ondansetron 32 mg/50 mL Injection - 50 mL Zofran 2 mg/mL Injection - 10 mL Zuplenz 4 mg and 8 mg oral soluble film - 12 films [If the answer to this question is no, a prior authorization is not required. These quantities are available without a prior authorization.] Is generic ondansetron or Zofran being requested? Y N [If the answer to this question is no, may skip to question 4.] Does the participant have a diagnosis of Hyperemesis Y N Gravidarum?

Prior Authorization Criteria Form

4.

5. 6. 7.

8.

9.

[If the answer to this question is yes, may skip to question 7.] Is the participant receiving moderate to highly emetogenic Y chemotherapy? [If the answer to this question is yes, may skip to question 10.] Is the participant receiving total body irradiation? Y [If the answer to this question is yes, may skip to question 10.] Is the participant receiving fractionated abdominal irradiation? Y [If the answer to this question is yes, may skip to question 10.] Has the participant had an inadequate treatment response to two Y of the following medications: vitamin B6, doxylamine, promethazine (Phenergan), trimethobenzamide (Tigan), or metoclopramide (Reglan)? [If the answer to this question is yes, may skip to question 9.] Is the participant intolerant to or had a confirmed adverse event Y with two of the following medications: vitamin B6, doxylamine, promethazine (Phenergan), trimethobenzamide (Tigan), or metoclopramide (Reglan)? [If the answer to this question is no, no further questions are needed.] Is generic ondansetron or Zofran being requested because the Y participant has a documented risk for hospitalization for rehydration? [No further questions are needed.]

N

N N N

N

N

10. How many days per month does the participant receive nausea/emesis-inducing therapy? Comments: I affirm that the information given on this form is true and accurate as of this date. Prescriber (Or Authorized) Signature and Date

Information

Prior Authorization Criteria Form

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Prior Authorization Criteria Form