Formulary Exception/prior Authorization Request Form
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2Formulary Exception/Prior Authorization Request Form
Patient Information
Prescriber Information
Patient Name:
Prescriber Name:
Patient ID#:
Address:
Address:
City:
State:
City:
State:
Home Phone:
Zip:
Office Phone #:
Office Fax #:
Zip:
DOB:
Contact Person at Doctor's Office:
Gender:
M or F
Diagnosis and Medical Information
Medication:
Strength:
Frequency:
Expected Length of Therapy:
Qty:
Day
If this is a continuation of therapy, how
Supply:
long has the patient been on the medication?
Diagnosis:
Diagnosis (ICD) Code(s):
FORM CANNOT BE EVALUATED WITHOUT REQUIRED CLINICAL INFORMATION
What condition is the drug being prescribed for? _________________________________________________________________________________________________
Please list all medications the patient has tried specific to the diagnosis and specify below:
Therapeutic failure, including length of therapy for each drug: _____________________________________________________________________________
Drugs (s) contraindicated: __________________________________________________________________________________________________________
Adverse event (e.g. toxicity, allergy) for each drug:_______________________________________________________________________________________
Is the request 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? Specify anticipated significant adverse event: ____________________________________________________
Does that patient have a chronic condition confirmed by diagnostic testing? If so, please provide diagnostic test and date: _____________________________________
Does the patient have a clinical condition for which other alternatives are not recommended based on published guidelines or clinical literature? If so, please provide
documentation: ___________________________________________________________________________________________________________________________
Does the patient require a specific dosage form (e.g., suspension, solution, injection)? If so, please provide dosage form: _____________________________________
Are additional risk factors (e.g., GI risk, cardiovascular risk, age) present? If so, please provide risk factors: ___________________________________________________
Other: Please provide additional relevant information: ____________________________________________________________________________________________
REQUIRED CLINICAL INFORMATION: PLEASE PROVIDE ALL RELEVANT CLINICAL DOCUMENTATION TO SUPPORT USE OF THIS MEDICATION.
PLEASE COMPLETE CORRESPONDING SECTION ON PAGE 2 FOR THE SPECIFIC DRUGS/CLASSES LISTED.
**FOR ANY DRUG/CLASS NOT LISTED ON THE BACK PAGE, PLEASE ATTACH ADDITIONAL INFORMATION, BUT CANNOT EXCEED TWO PAGES**
PRESCRIPTION BENEFIT PLAN MAY REQUEST ADDITIONAL INFORMATION OR CLARIFICATION, IF NEEDED, TO EVALUATE REQUESTS
PLEASE FAX COMPLETED FORM TO 1-888-836-0730
Expedited/Urgent Review Requested: By checking this box and signing below, I certify that applying the standard review time frame may seriously jeopardize the life or health
of the patient or the patient’s ability to regain maximum function.
I attest that the medication requested is medically necessary for this patient. I further attest that the information provided is accurate and true, and that documentation supporting this information is
available for review if requested by CVS Caremark, the health plan sponsor, or, if applicable, a state or federal regulatory agency. I understand that any person who knowingly makes or causes to be
made a false record or statement that is material to a claim ultimately paid by the United States government or any state government may be subject to civil penalties and treble damages under both
the federal and state False Claims Acts. See, e.g., 31 U.S.C. §§ 3729-3733.
Prescriber Signature: ________________________________________________________________________
Date: ______________________________
Confidentiality Notice: The documents accompanying this transmission contain confidential health information that is legally privileged. If you are not the intended recipient, you are hereby notified
that any disclosure, copying, distribution of these documents is strictly prohibited. If you have received this information in error, please notify the sender immediately (via return FAX) and arrange for
the return or destruction of these documents.
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