Active, Pre-Medicare and Medicare Without Part D Prior Authorization and Appeals
Pharmacy Prior Authorizations
This section contains information about the prior authorization (PA) of medications and other utilizations management information (UM) about covered drugs.
Pharmacy PA is a medical review that is required for coverage of certain medications such as those that:
- Are very high cost.
- Have specific prescribing guidelines.
- Are generally used for cosmetic purposes.
- Are limited in quantities.
Pharmacy Prior Authorization- intended to act as a safety and cost saving measure for the plan. The following are types of PA and UM. These measures are put in place to act as a safety and cost saving measure for the plan, by granting approval for drugs covered by the FDA for certain disease states.
- Access or Traditional PA- Reviews typically require that specific medical criteria is met before the medication is covered.
- Quantity Limit (QL)- Certain medications are limited in the quantity that you can receive per copay based on their recommended duration of therapy and/or routine use.
- Step Therapy (ST)- Requires you to first try a designated preferred drug to treat your medical condition before the plan covers another drug for the same condition. Some step therapy medications may also be limited in quantity.
- Brand Name, Non-Preferred medication and tier exception- A process that reviews a brand name or non-preferred drug when you are unable to tolerate the generic or preferred drugs.
To start a Prior Authorization
Follow these stops to request a prior authorization (PA) –Providers may contact CVS/caremark in two ways, either by calling the Prior Authorization (PA) line or by going online to Covermymeds.com or Electronic Prior Authorization Solutions | CoverMyMeds.
By phone, providers can call 800-294-5979 to start the PA process.
- If the PA request is approved, the provider’s office or the member will need to contact the pharmacy and have the claim processed for the medication or have the script sent to the pharmacy and then have the claim processed.
- If the PA request is denied, then the first level appeal process is listed in the PA denial letter and provides directions on how to file the First Level Appeal.
If the PA is denied, a first level appeal may be warranted:
First Level Appeal
- If the Prior Authorization request is denied, the provider may file an appeal to CVS/caremark, the provider must provide a statement to support the appeal request and should attach a copy of supporting documentation along with the statement for the appeal request.
- In order to appeal the Prior Authorization denial, the member or their provider must request the appeal in writing within 60 calendar days after the date of the denial notice from CVS/Caremark. The appeal request must be mailed or faxed to:
CVS Caremark Specialty Appeals Department
800 Biermann Court
Mount Prospect, IL 60056
If the first level appeal through CVS/caremark is denied, you will follow the instructions on the second page of the denial letter to file a second level appeal.