Prior Authorization Information

Prior Authorization Information

CVS Caremark Prior Authorization (PA) tools are developed to ensure safe, effective and appropriate use of selected drugs. Prior Authorization can ensure proper patient selection, dosage, drug administration and duration of selected drugs.

PA Forms for Physicians

When a PA is needed for a prescription, the member will be asked to have the physician or authorized agent of the physician contact our Prior Authorization Department to answer criteria questions to determine coverage.

Prior Authorization Products, Tools and Criteria

Drugs suitable for PA include those products that are commonly:

• subject to overuse, misuse or off-label use

• limited to specific patient population

• subject to significant safety concerns

• used for condition that are not included in the pharmacy benefit, such as cosmetic uses

• expensive

Prior Authorization tools are comprised of several different components including:

• Prior Authorization – A defined set of criteria under which a drug may be covered under a pharmacy benefit

• Post Step Therapy Prior Authorization – A defined set of criteria under which a specific quantity may be covered when the Step Therapy requirements have not been met

• Post Limit Prior Authorization – A defined set of criteria under which a specific quantity may be covered when a Drug Limitation has been exceeded

Prior Authorization tools are comprised of objective criteria that are based on sound clinical evidence. Our PA criteria are:

• based on the latest FDA-approved product labeling, uses listed in authorized compendia supported by an adequate level of clinical evidence, national guidelines and peer-reviewed literature published in scientific journals where the drug is recommended as safe and effective

• internally reviewed by one CVS Caremark physician

• externally reviewed by credentialed practitioners

• updated yearly and when the drug indication or safety information changes

• structured to meet applicable standards for National Committee for Quality Assurance (NCQA), American Accreditation HealthCare Commission (URAC), state or Federal agencies

*May not result in near real-time decisions for all prior authorization types and reasons.

Contact CVS Caremark Prior Authorization Department

Medicare Part D

• Phone: 1-855-344-0930

• Fax: 1-855-633-7673

• If you wish to request a Medicare Part Determination (Prior Authorization or Exception request), please see your plan’s website for the appropriate form and instructions on how to submit your request.

Medicaid

• Phone: 1-877-433-7643

• Fax: 1-866-255-7569

• Medicaid PA Request Form

• Medicaid PA Request Form (New York)

• Medicaid PA Request Form (Minnesota)

Non-Medicare

• Phone: 1-800-294-5979

• Fax: 1-888-836-0730

• Global Prior Authorization Form

• Download Non-Medicare Prior Authorization Forms

• Preventive Services Contraceptive Zero Copay Exceptions Form

• Preventive Services Contraceptive Zero Copay Exceptions Process

Request for Peer-to-Peer Discussion:

If the prescriber would like to discuss a prior authorization determination with a clinical peer, please contact the CVS/caremark Prior Authorization Department toll-free at 1-800-294-5979 and we will arrange to make a clinician available for discussion.

State Requirements

• Arizona Appeal Information Packet

• Arizona State PA Request Form

• Arkansas State PA Request Form

• Arkansas Step Therapy Protocol Exception Process

• California State PA Request Form

• Colorado Standard Contraceptive Exceptions Form

• Colorado State PA Request Form

• Connecticut Step Therapy Exception Disclosure

• Delaware State PA Request Form

• Florida State PA Request Form

• Florida State PA Request Form (Specialty)

• Florida Requesting a Step Therapy Exemption

• Florida Step Therapy Exemption Form

• Illinois State PA Request Form

• Louisiana State PA Request Form

• Massachusetts Chemotherapy PA Request Form

• Massachusetts State PA Request Form

• Massachusetts Hepatitis C PA Request Form

• Massachusetts Synagis PA Request Form

• Michigan ePA Required Coversheet and State PA Request Form

• Minnesota State PA Request Form (Commercial)

• Minnesota State PA Request Form (Exchange)

• Minnesota Step Therapy Exception Form

• Mississippi State PA Request Form

• Nevada Step Therapy Protocol Exception Process

• New Hampshire State PA Request Form

• New Mexico State Drug Prior Authorization Form

• Oregon State PA Request Form

• Tennessee Step Therapy Protocol Exception Process

• Texas State PA Request Form

• Washington Exception Process

• West Virginia PA Request Form

Hours: Monday through Friday 8:00am to 6:00pm CST