Clinical Prior Authorization Criteria Request Form

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CLINICAL PRIOR AUTHORIZATION CRITERIA
REQUEST FORM
Please complete this form and fax it to CVS Caremark at 1-888-836-0730 to receive a DRUG SPECIFIC
CRITERIA FORM for prior authorization. Once received, a DRUG SPECIFIC CRITERIA FORM
will be faxed to the specific physician along with patient specific information, appropriate criteria for
the request and questions that must be answered. Once received, reviewed and approved an override
will be processed and the pharmacist can resubmit the claim for payment. If the request is denied, the
physician and patient will be sent a notification and reason for the denial.
ALL fields must be completed before faxing. Please fax the completed form to CVS Caremark at
1-888-836-0730.
SECTION I: PATIENT INFORMATION
LAST NAME, FIRST NAME (PLEASE PRINT)
DOB (MM/DD/YYYY)
STREET ADDRESS
PHONE NUMBER
(
)
CITY
STATE
CARDHOLDER ID #
ZIP CODE
SECTION II: DRUG INFORMATION
DRUG NAME (PLEASE PRINT)
DRUG STRENGTH
SECTION III: PHYSICIAN INFORMATION
PHYSICIAN NAME (PLEASE PRINT)
PHYSICIAN ADDRESS (STREET, CITY, STATE, ZIP CODE)
PHYSICIAN PHONE NUMBER
PHYSICIAN FAX NUMBER
(
)
(
)
SIGNATURE
DATE
DISCLAIMER: Incomplete or illegible forms and missing fields may delay the processing of your
request. Please complete all fields to ensure appropriate processing.
CONFIDENTIALITY NOTICE:
This communication and any attachments may contain confidential and/or privileged information for the
use of the designated recipients named above. If you are not the intended recipient, you are hereby notified that you have received this
communication in error and that any review, disclosure, dissemination, distribution, or copying of it or its contents is prohibited. If you have received
.
this communication in error, please notify the sender immediately by telephone and destroy all copies of this communication and any attachments
PRIVACY DISCLAIMER:
Plan participant privacy is important to us. Our employees are trained regarding the appropriate way to handle
plan participants’ private health information.
5274-13630A

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