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Get Clinical Prior Authorization Criteria Request Form
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How to fill out the CLINICAL PRIOR AUTHORIZATION CRITERIA REQUEST FORM online
Filling out the Clinical Prior Authorization Criteria Request Form is an essential step in obtaining necessary approvals for medication usage. This guide provides clear, step-by-step instructions to help users complete the form accurately and efficiently.
Follow the steps to successfully complete the form online.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- In Section I, complete the patient information. Provide the patient's last name, first name, date of birth in the format MM/DD/YYYY, street address, phone number, city, state, cardholder ID number, and zip code.
- In Section II, enter the drug information. This includes the drug name and drug strength. Ensure that all entries are printed clearly.
- In Section III, fill in the physician information. Provide the physician's name, address (including street, city, state, and zip code), phone number, signature, fax number, and date.
- Review all entries to ensure that every field is completed accurately. Incomplete or illegible forms may delay processing.
- Once the form is filled out, save your changes. Depending on your preference, you can also download, print, or share the completed form.
- Finally, fax the completed form to CVS Caremark at 1-888-836-0730.
Take action now by completing the Clinical Prior Authorization Criteria Request Form online!
Our PA criteria are: based on the latest FDA-approved product labeling, uses listed in authorized compendia supported by an adequate level of clinical evidence, national guidelines and peer-reviewed literature published in scientific journals where the drug is recommended as safe and effective.