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Get Cvs Caremark Prior Authorization Form For

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 patient been on an MAOI drug in the previous 14 days MAOI drugs include tranylcypromine and Is the prescriber a psychiatrist with experience prescribing both monoamine oxidase inhibitor MAOI drugs and amphetamine/ drugs In light of the boxed warning has the prescriber weighed/considered the benefits of treatment versus the potential risks of serious cardiovascular events including sudden death associated with the use of amphetamine products Comments I affirm that the information given on this form is true and accurate as of this date. Prior Authorization Criteria Form CVS/CAREMARK FAX FORM Amphetamines This fax machine is located in a secure location as required by HIPAA regulations. 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 patient been on an MAOI drug in the previous 14 days MAOI drugs include tranylcypromine and Is the prescriber a psychiatrist with experience prescribing both monoamine oxidase inhibitor MAOI drugs and amphetamine/ drugs In light of the boxed warning has the prescriber weighed/considered the benefits of treatment versus the potential risks of serious cardiovascular events including sudden death associated with the use of amphetamine products Comments I affirm that the information given on this form is true and accurate as of this date.

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