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Prior Authorization Information

Electronic Prior Authorizations

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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.

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
Non-Medicare
  • Phone: 1-800-294-5979
  • Fax: 1-888-836-0730
Hours: Monday through Friday 8:00am to 6:00pm CST
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