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

Drug Name (select from list of drugs shown) Amitiza (lubiprostone)

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: ICD Code: Please circle the appropriate answer for each applicable question. Y N 1. Does the patient have known or suspected mechanical gastrointestinal obstruction? (Examples include obstruction due to adhesions, tumors, hernias, cysts, abscess, etc.) [If the answer to this question is yes, then no further questions are required.] Y N 2. Is the patient greater than or equal to 18 years of age? Y N 3. Does the patient have a diagnosis of chronic idiopathic constipation (constipation for more than 6 months not due to any other identifiable disease or drug)? [If the answer to this question is yes, then no further questions are required.] Y N 4. Is Amitiza being used to treat irritable bowel syndrome with constipation (IBS-C) in women? Comments:

I affirm that the information given on this form is true and accurate as of this date.

Prescriber (Or Authorized) Signature and Date


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