Prior Authorization Information

Prior Authorization

Prior Authorization is a review process that a member’s health plan uses to make sure the medications, tests and treatments they receive are clinically appropriate safe, and affordable.

Prior Authorization can help:

• Provide coverage and potentially lower the member's medication costs.
• Make sure that the member receives the safest, most effective medication for the member’s condition.
• Decrease the chance that the member will have interactions with a medication that the member is already taking.

Drugs that typically require Prior Authorization include those that are commonly:

• Subject to overuse, misuse or off-label use.
• Limited to specific patient population.
• Subject to significant safety concerns.
• Used for conditions not included in the pharmacy benefit, such as cosmetic  purposes.
• Expensive.

The term Prior Authorization may be used by your plan to include (1) exception reviews for quantity limitations, (2) step therapy protocol and/or (3) non-formulary drug coverage.

When a Prior Authorization is needed for a prescription, the member will be asked to have the health care provider or an authorized agent of the health care provider contact CVS Caremark^® Prior Authorization Department to answer criteria questions to determine coverage.

The health care provider or their authorized agent may submit a request for Prior Authorization (depending on the plan) electronically (ePA), by fax or telephone.

For more information on submitting an ePA request, please visit this page.

If you wish to submit a Prior Authorization request by phone or fax, please contact the appropriate Prior Authorization Department.

Hours: Monday through Friday 8AM to 6PM CST

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 (Minnesota)

Non-Medicare

• Phone: 1-800-294-5979
• Fax: 1-888-836-0730
• Global Prior Authorization Form
• Preventive Services Contraceptive Zero Copay Exceptions Process

State-Specific Requirements and PA Forms

• 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 Prior Authorization Request Process
• Colorado Standard Contraceptive Exceptions Form
• Colorado State PA Request Form
• Colorado Serious Mental Illness Step Therapy Exception 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
• Kentucky Step Therapy Exception 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