Medical Necessity Criteria - Non-Covered Drugs Prior Authorization Form

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Medical Necessity Criteria – Non-Covered Drugs
Prior Authorization Form
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 1-888-487-9257.
Please contact CVS/Caremark at 1-800-294-5979 with questions regarding the prior authorization process.
When conditions are met, we will authorize the coverage of the requested drug.
Drug Name:__________________________________________________________________
Quantity_______________
Frequency_______________
Strength______________
Route of
Expected Length of
Administration_______________
Therapy_________________
Patient Information
Patient Name:
Patient ID:
Patient Group No.:
Patient DOB:
Patient Phone:
Prescribing Physician
Physician Name:
Physician Phone:
Physician Fax:
Physician Address:
City, State, Zip:
Diagnosis:
ICD Code:
Comments:
Please circle the appropriate answer for each question.
1.
Is the requested drug being used for an FDA-Approved indication OR an
Y
N
indication supported in the compendia of current literature (examples:
AHFS, Micromedex, current accepted guidelines)?
2.
Has the patient tried and had an inadequate treatment response or
Y
N
intolerance to formulary alternatives for the given diagnosis?
Requirement: 3 in a class with 3 or more alternatives, 2 in a class with 2
alternatives, or 1 in a class with only 1 alternative
Drug Name______________________ Trial Year______
Reason for Failure:
Drug Name______________________ Trial Year______
Reason for Failure:
Drug Name______________________ Trial Year______
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