Prior Authorization Form
PASSPORT HEALTH PLAN KENTUCKY MEDICAID
This fax machine is located in a secure location as required by HIPAA regulations.
Complete/review information, sign and date. Fax signed forms to CVS/Caremark at 1-844-802-1406.
Please contact CVS/Caremark at 1-844-380-8831 with questions regarding the prior authorization process.
When conditions are met, we will authorize the coverage of Evzio.
Drug Name (select from list of drugs shown)
Other, Please specify
Route of Administration
Expected Length of Therapy
Patient Group No.:
City, State, Zip:
Please circle the appropriate answer for each question.
Does the patient require emergency treatment of known or suspected
opioid overdose, as manifested by respiratory and/or central nervous
system depression; intended for immediate administration as emergency
therapy in settings where opioids may be present?
[If no, then no further questions.]
Has the patient had a documented therapeutic failure of Narcan Nasal
Spray OR naloxone 2 mg/2 mL injection (off-label intranasal use)?
[Note: Documentation MUST include paid claims AND chart documentation from the provider supporting
contraindication to preferred alternatives.]
I affirm that the information given on this form is true and accurate as of this date.
Prescriber (Or Authorized) Signature and Date