Prior Authorization Prescriber Fax Form
<Plan Name>
Bydureon (exenatide) (Coverage Determination)
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 1-855-633-7673.
Please contact CVS/Caremark at 1-800-294-5979 with questions regarding the prior authorization process.
When conditions are met, we will authorize the coverage of Bydureon (Coverage Determination).
Drug Name (select from list of drugs shown)
Bydureon (exenatide)
Patient Information
Patient Name:
Patient ID:
Patient Phone 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. Does the patient have a creatinine clearance of greater than
30mL per minute or normal kidney function?
Y N
[If the answer to this question is no, then no further questions are required.]
2. Does the patient have a history of pancreatitis?
Y N
[If the answer to this question is yes, then no further questions are required.]
3. Does the patient have a personal or family history of medullary
thyroid carcinoma (MTC)?
Y N
[If the answer to this question is yes, then no further questions are required.]
4. Does the patient have Multiple Endocrine Neoplasia syndrome
type 2 (MEN 2)?
Y N
[If the answer to this question is yes, then no further questions are required.]
5. Does the patient have a diagnosis of type 2 diabetes mellitus?
Y N
[If the answer to this question is no, then no further questions are required.]
6. Has the patient been receiving Bydureon therapy for at least 3
months?
Y N
[If the answer to this question is no, then skip to question 8.]
7. Has the patient demonstrated an expected reduction in HbA1c
since starting Bydureon therapy?
Y N
[No further questions are required.]
8. Is the patient being switched from Byetta or Victoza therapy?
Y N
[If the answer to this question is yes, no further questions are required.]
9. Does the patient have an HbA1c level greater than 7 percent?
Y N
[If the answer to this question is no, then no further questions are required.]
10. Has the patient demonstrated an inadequate treatment
response, contraindication or been intolerant to metformin OR
a sulfonylurea OR a thiazolidinedione?
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