eForms Logo

CVS/Caremark Prior (Rx) Authorization Form

CVS/Caremark Prior (Rx) Authorization Form

Updated June 02, 2022

A CVS/Caremark prior authorization form is to be used by a medical office when requesting coverage for a CVS/Caremark plan member’s prescription. A physician will need to fill in the form with the patient’s medical information and submit it to CVS/Caremark for assessment. In doing so, CVS/Caremark will be able to decide whether or not the requested prescription is included in the patient’s insurance plan. If you would like to view forms for a specific drug, visit the CVS/Caremark webpage, linked below.

How to Write

Step 1 – In “Patient Information”, provide the patient’s full name, ID number, full address, phone number, date of birth, and gender.

Step 2 – In “Prescriber Information”, provide the prescriber’s full name, full address, office phone number, office fax number, and supply a name of a contact person.

Step 3 – In “Diagnosis and Medical Information”, specify the medication, strength, frequency, expected length of therapy, quantity, and day supply. If this is a continuation therapy, specify how long the patient has been on this medication. Lastly, supply the diagnosis and diagnosis ICD code(s).

Step 4 – Next, specify the following: what condition the drug is being prescribed for, any therapeutic failure(s) (including length of therapy for each drug), contraindicated drug(s) and any adverse effects for each drug.

Step 5 – Specify whether or not the request is for a patient with one or more chronic conditions (e.g., psychiatric condition, diabetes) who is stable on the current drug(s) and who might be at high risk for a significant adverse event with a medication change. Also, mention any anticipated significant adverse events.

Step 6 – Specify whether or not the patient has a chronic condition confirmed by diagnostic testing. If so, provide diagnostic test and date.

Step 7 – Specify whether or not the patient has a clinical condition for which other alternatives are not recommended based on published guidelines or clinical literature. If so, provide documentation.

Step 8 – Specify whether or not the patient requires a specific dosage form (e.g., suspension, solution, injection). If so, provide dosage form.

Step 9 – Specify whether or not there are additional risk factors (e.g., GI risk, cardiovascular risk, age) present. If so, provide risk factors.

Step 10 – Provide any additional relevant information.

Step 11 – The prescriber must provide their signature as well as the date at the bottom of page 1.

Step 12 – On page 2, specify the type of medication requested and select yes or no in response to the questions related to each specific drug.

By using the website, you agree to our use of cookies to analyze website traffic and improve your experience on our website.