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Cvs caremark formulary exception prior authorization request form 2025

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The document is a Physician Prior Authorization Request Form for specific medications (Naprelan, Pennsaid, Sprix, Zipsor, Zorvolex) used by BlueChoice® HealthPlan. It collects patient and provider information and includes a series of questions to determine the necessity of the requested drug based on FDA approval, previous treatment failures with generic NSAIDs, contraindications, adverse reactions, and adherence to dosing guidelines. The form must be faxed to Caremark for processing.

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

How do I submit a formulary exception?

Your doctor is your ally on this. Most plans require that your doctor submit a formulary exception on your behalf. The doctor will need to send paperwork to your health plan indicating the reason that you cant take the preferred medications and must have one that is not currently on the formulary.

What triggers a prior authorization?

Prior authorizations are usually only required for more costly, involved treatments where an alternative is available. For instance, if a physician prescribes an invasive procedure such as orthopedic surgery, it will likely require preauthorization.

Can I get a prescription without prior authorization?

Prior authorization is usually required if you need a complex treatment or prescription. Coverage will not happen without it.

Can I get my medication without prior authorization?

Prior authorization requires your doctor or provider to obtain approval from your health plan before providing health care services or prescribing prescription drugs. Without prior authorization, your health plan may not pay for your treatment or medication. (Emergency care doesnt need prior authorization.)

What are prior authorization and the formulary exception process?

What Are Prior Authorization and the Formulary Exception Process? The term prior authorization may also refer to a commonly used managed care strategy called the formulary exception process, which allows exceptions to a plans formulary (see A M C P s Concept Series paper, Form u l a ry Management).

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Key Facts about the Physician Prior Authorization Request Form

HIPAA Compliance

Drug Indication Requirement

Documentation for NSAID Intolerance

Adverse Reactions Documentation

Clinical Condition Justification

Dosing Guidelines Compliance

Contact Information for Queries

HIPAA Compliance

The form must be faxed to Caremark at a secure, HIPAA-compliant location.

Drug Indication Requirement

The requested drug must be prescribed for an FDA-approved indication; otherwise, no further questions are required.

Documentation for NSAID Intolerance

If the participant has failed or is intolerant to generic NSAIDs, documentation of medication trials and reasons for failure must be submitted.

Adverse Reactions Documentation

Participants with documented adverse reactions to generic NSAIDs need to provide details and documentation of those reactions.

Clinical Condition Justification

If there is no formulary agent available for the participant's clinical condition, supporting documentation must be included.

Dosing Guidelines Compliance

The prescribed drug must fall within the manufacturer’s dosing guidelines or accepted literature; otherwise, it may not be approved.

Contact Information for Queries

For any questions regarding prior authorization procedures, Caremark can be contacted at 800-294-5979.

Why is prior authorization necessary?

Prior authorization (PA) is an essential tool that is used to ensure that drug benefits are administered as designed and that plan members receive the medication therapy that is safe, effective for their condition, and provides the greatest value.

Do all medications need prior authorization?

Not everything requires prior authorization. Theres a relatively easy way to check for both prescription drugs and medical services. There are two ways to check which drugs are covered by your plan. Check the list of covered drugs, also known as the drug formulary.

Cvs caremark formulary exception prior authorization request form 2025

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The best way to modify Cvs caremark formulary exception prior authorization request form in PDF format online

Complete this form in 5 minutes or less

Got questions?

How do I submit a formulary exception?

What triggers a prior authorization?

Can I get a prescription without prior authorization?

Can I get my medication without prior authorization?

What are prior authorization and the formulary exception process?

Key Facts about the Physician Prior Authorization Request Form

HIPAA Compliance

Drug Indication Requirement

Documentation for NSAID Intolerance

Adverse Reactions Documentation

Clinical Condition Justification

Dosing Guidelines Compliance

Contact Information for Queries

HIPAA Compliance

Drug Indication Requirement

Documentation for NSAID Intolerance

Adverse Reactions Documentation

Clinical Condition Justification

Dosing Guidelines Compliance

Contact Information for Queries

People also ask

Why is prior authorization necessary?

Do all medications need prior authorization?

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