Kineret

Prior Authorization Request

CVS Caremark administers the prescription benefit plan for the patient identified. This patient’s benefit plan requires prior authorization for certain
medications in order for the drug to be covered. To make an appropriate determination, providing the most accurate diagnosis for the use of the
prescribed medication is necessary. Please respond below and fax this form to CVS Caremark toll-free at 1-866-249-6155. If you have questions
regarding the prior authorization, please contact CVS Caremark at 1-866-814-5506. For inquiries or questions related to the patient’s eligibility, drug
copay or medication delivery; please contact the Specialty Customer Care Team: CaremarkConnect® 1-800-237-2767.

Patient Name: _____________________________ Date: ________________________________

Patient’s ID: _______________________________ Patient’s Date of Birth: ________________
Physician’s Name: _______________________________________________________________________
Specialty: _________________________________ NPI#: ________________________________
Physician Office Telephone: __________________ Physician Office Fax: ___________________
The indicated diagnosis (including any applicable labs and/or tests) and medication usage
must be supported by documentation from the patient’s medical records.
1. Which drug is being prescribed?  Kineret  Other ___________________
2. What is the patient's diagnosis?
 Rheumatoid arthritis (RA)  Other ____________________________________
3. What is the ICD9? _______________
4. What is the patient's age? _______________
5. Does the patient have a known hypersensitivity to E. coli derived proteins, Kineret, or any of its components?
 Yes  No
6. Is the patient currently receiving Kineret therapy?  Yes  No If No, skip to #8
7. Is the patient tolerating and responding to Kineret and there continues to be a medical need for the medication?
 Yes  No No further questions

Complete the following questions if patient is NOT currently receiving Kineret

8. Did the patient fail or is intolerant to at least one disease modifying antirheumatic drug (DMARD)?  Yes  No
9. Did the patient fail or is intolerant to methotrexate?  Yes  No
10. Did the patient fail or is intolerant to Enbrel?  Yes  No
11. Did the patient fail or is intolerant to Humira?  Yes  No

Information given on this form is accurate as of this date:

X_______________________________________________________________________
Prescriber or Authorized Signature Date (mm/dd/yy)

Send completed form to: Case Review Unit CVS Caremark Specialty Programs Fax: 1-866-249-6155
Note: This fax may contain medical information that is privileged and confidential and is solely for the use of individuals named above. If you are not the intended
recipient you hereby are advised that any dissemination, distribution, or copying of this communication is prohibited. If you have received the fax in error, please
immediately notify the sender by telephone and destroy the original fax message. Kineret FCHP - 4/2013
CVS Caremark Specialty Pharmacy ● 2211 Sanders Road NBT-6 ● Northbrook, IL 60062
Phone: 1-866-814-5506 ● Fax: 1-866-249-6155 ● www.caremark.com
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