02/26/2015 Prior Authorization Form CHRISTUS Health Plan (Medicaid) Januvia 100mg (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 100mg (Medicaid). Drug Name (select from list of drugs shown) Januvia 100mg 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 have a history of moderate renal failure in the last 730 days? Y N [If the answer to this question is yes, then no further questions required] 4. Does the patient have a history of severe renal failure or End Stage Renal Disease (ESRD) in the last 730 days? Y N [If the answer to this question is yes, then no further questions required.] 5. Is the dose less than or equal to 100 mg per day? 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