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Complete/review information sign and date. Fax signed forms to CVS Caremark at 1-888-836-0730. Please contact CVS Caremark at 1-888-414-3125 with questions regarding the prior authorization process. When conditions are met we will authorize the coverage of Amphetamines. Drug Name select from list of drugs shown amphetamine mixture mixture SR Patient Information Patient Name Patient ID Patient Group No. Prescribing Physician Physician Name Physician Phone Physician Fax Physician Address City State Zip Diagnosis ICD Code Please circle the appropriate answer for each applicable question. Is the patient 3 years of age or older Y N Does the patient have a diagnosis of Attention-Deficit Hyperactivity Disorder ADHD or Attention Deficit Disorder ADD If the answer to this question is yes skip to question 6. Is the medication being prescribed or Has the diagnosis been confirmed by sleep studies Will the patient be on a monoamine oxidase inhibitor MAOI drug while taking this therapy or has the pa....

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PLEASE FAX COMPLETED FORM TO 1-888-836-0730. I further attest that the information provided is accurate and true, and t hat documentation supporting this inf ormation is available for review if requested by CVS Caremarkâ„¢, the health plan sponsor, or, if applicable, a state or federal regulatory agency.

In 2014, the corporate name for CVS Caremark became CVS Health, with CVS Caremark becoming a subsidiary.

Did you know submitting prior authorizations (PAs) by fax or phone can take anywhere from 16 hours to 2 days to receive a determination? CVS Caremark has made submitting PAs easier and more convenient. Some automated decisions may be communicated in less than 6 seconds!

Prior authorization is an approval of coverage from your insurance company, not your doctor. It's a restriction put in place to determine whether or not they will pay for certain medicines. It doesn't affect cash payment for prescriptions. Plus it's only required on those prescriptions when billed through insurance.

What is the process to request a prior authorization? You or your pharmacy can ask your doctor to start a PA. Then, your doctor can submit an electronic prior authorization request to Caremark. Information for providers about this process is available at .caremark.com/epa.

What is prior authorization? This means we need to review some medications before your plan will cover them. We want to know if the medication is medically necessary and appropriate for your situation. If you don't get prior authorization, a medication may cost you more, or we may not cover it.

Prior Authorization Information CVS Caremark Prior Authorization (PA) tools are developed to ensure safe, effective and appropriate use of selected drugs. Prior Authorization can ensure proper patient selection, dosage, drug administration and duration of selected drugs.

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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232