Loading
Form preview picture

Get CVS 91-13393a

BRAND PENALTY EXCEPTION REQUEST Complete this form to allow the patient to receive a brand-name drug instead of a generic alternative and pay only the appropriate brand copayment. Patient Information Prescriber Information Patient Name Prescriber Name Date of Birth Prescriber Phone Number Plan Participant ID Number Prescriber Fax Number NOTE The following sections must be completed by the prescriber. Incomplete or missing information may delay processing and result in the form being returned to the requestor. Brand Drug Name Strength Dosage Form Diagnosis Please answer each of the following questions 1. What generic alternative s has the patient tried or has been considered 2. Provide evidence that the generic alternative s is unsafe or ineffective or has known interactions with other drugs the patient is currently taking. 3. Additional information pertinent to the patient s condition and request As the prescriber for the brand-name drug above I certify that the information provided is accurate and complete. Prescriber Signature Date Fax completed form to the CVS Caremark Appeals Department toll-free at 1-866-689-3092. 2008 Caremark. All rights reserved* This document contains confidential and proprietary information of CVS Caremark and cannot be reproduced distributed or printed without written permission from CVS Caremark. Copayment copay or coinsurance means the amount a plan participant is required to pay for a prescription in accordance with a Plan which may be a deductible a percentage of the prescription price a fixed amount or other charge with the balance if any paid by a Plan* 91-13393a. Patient Information Prescriber Information Patient Name Prescriber Name Date of Birth Prescriber Phone Number Plan Participant ID Number Prescriber Fax Number NOTE The following sections must be completed by the prescriber. Incomplete or missing information may delay processing and result in the form being returned to the requestor. Incomplete or missing information may delay processing and result in the form being returned to the requestor. Brand Drug Name Strength Dosage Form Diagnosis Please answer each of the following questions 1. What generic alternative s has the patient tried or has been considered 2. Brand Drug Name Strength Dosage Form Diagnosis Please answer each of the following questions 1. What generic alternative s has the patient tried or has been considered 2. Provide evidence that the generic alternative s is unsafe or ineffective or has known interactions with other drugs the patient is currently taking. Provide evidence that the generic alternative s is unsafe or ineffective or has known interactions with other drugs the patient is currently taking. 3. Additional information pertinent to the patient s condition and request As the prescriber for the brand-name drug above I certify that the information provided is accurate and complete. 3. Additional information pertinent to the patient s condition and request As the prescriber for the brand-name drug above I certify that the information provided is accurate and complete. Prescriber Signature Date Fax completed form to the CVS Caremark Appeals Department toll-free at 1-866-689-3092. .

How It Works

cvs caremark brand exception form rating
4.86Satisfied
36 votes

Tips on how to fill out, edit and sign Brand caremark s online

How to fill out and sign Form brand penalty online?

Get your online template and fill it in using progressive features. Enjoy smart fillable fields and interactivity. Follow the simple instructions below:

Getting a legal professional, making an appointment and coming to the workplace for a personal meeting makes completing a CVS 91-13393a from beginning to end stressful. US Legal Forms helps you to quickly create legally-compliant papers according to pre-built web-based samples.

Perform your docs in minutes using our straightforward step-by-step instructions:

  1. Get the CVS 91-13393a you want.
  2. Open it using the online editor and start altering.
  3. Fill out the empty areas; involved parties names, places of residence and phone numbers etc.
  4. Change the blanks with smart fillable fields.
  5. Put the particular date and place your e-signature.
  6. Click on Done following twice-examining all the data.
  7. Download the ready-produced document to your gadget or print it out as a hard copy.

Easily create a CVS 91-13393a without having to involve specialists. There are already more than 3 million customers making the most of our unique catalogue of legal documents. Join us right now and get access to the top collection of browser-based blanks. Give it a try yourself!

Get form

Experience a faster way to fill out and sign forms on the web. Access the most extensive library of templates available.

Video instructions and help with filling out and completing brand exception only

Cvs caremark exception FAQ

Get This Form Now!

Use professional pre-built templates to fill in and sign documents online faster. Get access to thousands of forms.

Keywords relevant to cvs exception

  • cvs caremark brand exception
  • caremark form penalty
  • caremark exception
  • brand form name
  • brand exception
  • 91-13393a
  • requestor
  • interactions
  • reproduced
  • PROPRIETARY
  • certify
  • participant
  • ineffective
  • deductible
  • pertinent
If you believe that this page should be taken down, please follow our DMCA take down processhere.
Ensure the security of your data and transactions

USLegal fulfills industry-leading security and compliance standards.

  • 
                            VeriSign logo picture

    VeriSign secured

    #1 Internet-trusted security seal. Ensures that a website is free of malware attacks.

  • Accredited Business

    Guarantees that a business meets BBB accreditation standards in the US and Canada.

  • 
                            TopTenReviews logo picture

    TopTen Reviews

    Highest customer reviews on one of the most highly-trusted product review platforms.