Your prescriber fills out and submits the CVS Caremark prior authorization form to get a medication covered when the plan requires clinical review before paying. The form captures patient details, drug information, and the prescriber’s clinical rationale, then goes to CVS Caremark by fax, phone, or electronic portal. For commercial (non-Medicare) plans, the fax number is 1-888-836-0730 and the phone line is 1-800-294-5979, Monday through Friday, 8 a.m. to 6 p.m. CST.1CVS Caremark. Prior Authorization Standard requests are typically decided within 72 hours, and urgent requests within 24 hours.
Where to Get the Form
CVS Caremark publishes a general-purpose prior authorization request form that works for most non-Medicare plans. Prescribers can download it directly from the CVS Caremark site.2CVS Caremark. Clinical Prior Authorization Criteria Request Form For certain drug classes, there are condition-specific forms with targeted clinical questions. The GLP-1 agonist form, for example, asks about the diabetes diagnosis and prior therapies tried.3CVS Health. Antidiabetic GLP-1, GIP-GLP-1 Agonists Some states require their own standardized uniform form, like New Mexico’s, which CVS Caremark hosts alongside its general form.4CVS Caremark. New Mexico Uniform Prior Authorization Form
Prescribers who want to skip paper can use CVS Caremark’s electronic prior authorization system, which runs through CoverMyMeds and Surescripts. Both are free, available as web portals, and can integrate directly with an electronic health record.5CVS Caremark. Electronic Prior Authorization Electronic submission is faster and avoids the legibility and lost-fax problems that follow paper.
What the Form Asks For
The general form has three sections. Getting every field right the first time matters. If CVS Caremark receives an incomplete submission, they will request the missing information, and the clock pauses while the office responds.6CVS Health. Prior Authorization Process
Patient Information
The first section captures the patient’s identity and plan enrollment: full name, date of birth, street address, phone number, and the cardholder ID number found on the front of the prescription benefits card.2CVS Caremark. Clinical Prior Authorization Criteria Request Form The cardholder ID is how CVS Caremark matches the request to the correct benefit plan, so a single transposed digit can cause a rejection.
Drug Information
The second section identifies what is being prescribed. The prescriber enters the medication name and strength. On condition-specific forms and state-mandated forms, the prescriber also provides the ICD-10 diagnosis code, the quantity requested, and the anticipated duration of therapy.4CVS Caremark. New Mexico Uniform Prior Authorization Form The medication name should match the plan’s formulary listing. Writing a brand name when the form expects the generic (or the reverse) can cause a mismatch.
Prescriber Information and Clinical Justification
The third section identifies the prescriber and explains why this drug is necessary. The prescriber provides name, office address, phone and fax numbers, and signs and dates the form.2CVS Caremark. Clinical Prior Authorization Criteria Request Form State-mandated and condition-specific forms also require the prescriber’s ten-digit National Provider Identifier.4CVS Caremark. New Mexico Uniform Prior Authorization Form
The clinical justification is where approvals are won or lost. The prescriber should document medical necessity by attaching or summarizing relevant lab results, listing previous medications that failed or caused adverse effects, and explaining why formulary alternatives are not appropriate. For step therapy overrides, the prescriber should name the specific lower-tier drugs the patient already tried and describe why they didn’t work. Vague statements without supporting detail are the fastest path to a denial.
Where to Send It, by Plan Type
CVS Caremark accepts the form by phone, fax, or electronic portal. The phone and fax numbers depend on the patient’s plan:1CVS Caremark. Prior Authorization
- Medicare Part D: phone 1-855-344-0930, fax 1-855-633-7673
- Medicaid: phone 1-877-433-7643, fax 1-866-255-7569
- Non-Medicare commercial plans: phone 1-800-294-5979, fax 1-888-836-0730
Phone lines run Monday through Friday, 8 a.m. to 6 p.m. CST. Fax is available around the clock, and many offices prefer it because the transmission confirmation page becomes a record.
The faster option is electronic submission through CoverMyMeds or Surescripts.5CVS Caremark. Electronic Prior Authorization Registration is free and takes a few minutes. If the prescriber’s EHR already integrates with either platform, the request goes out without leaving the patient’s chart, and it feeds directly into CVS Caremark’s review queue with no scanning or mailing delay.
How Long a Decision Takes
Turnaround depends on urgency. CVS Caremark’s published process gives these timeframes:6CVS Health. Prior Authorization Process
- Urgent pre-service requests: must be completed within 72 hours of receipt; CVS Caremark’s internal standard is 24 hours.
- Non-urgent pre-service requests: must be completed within 15 days; internal standard is 72 hours.
- Post-service reviews: completed within 30 calendar days.
If clinical information is missing, CVS Caremark will contact the prescriber within 24 hours and allow at least 48 hours for a response. The decision clock pauses during that window, which is why getting the form right the first time saves real days. Both the prescriber and the patient receive written notice of the decision. To check status on a pending request, call the customer care number on the back of the prescription benefits card.7State of Louisiana Office of Group Benefits. CVS Caremark Prior Authorizations and Appeals Program
Getting Medication While You Wait
If you need the drug immediately and the authorization is still pending, ask your pharmacist about an emergency supply. Many benefit plans allow pharmacies to dispense a short temporary supply, commonly 72 hours’ worth, when a pharmacist determines that going without the medication could harm you. Rules vary by plan and by state, so not every pharmacy or every drug qualifies. Controlled substances and certain specialty medications are often excluded.
If the pharmacy cannot provide an emergency supply, your prescriber can call CVS Caremark directly and request an urgent review. CVS Caremark keeps a pharmacist or physician available around the clock for authorization of medically necessary services.6CVS Health. Prior Authorization Process An urgent-flagged request is typically reviewed within 24 hours rather than the standard 72.
If the Request Is Denied
A denial letter goes to both prescriber and patient, explaining the reason and how to appeal.7State of Louisiana Office of Group Benefits. CVS Caremark Prior Authorizations and Appeals Program Common reasons include insufficient clinical documentation, no evidence that required step therapy drugs were tried first, or a diagnosis that doesn’t match the plan’s coverage criteria for that medication. A denial is the start of an appeal, not the end of coverage.
Internal Appeals
You or your prescriber must file the first-level appeal within 180 days of the denial letter. CVS Caremark reviews it, with any new supporting documentation, within these windows:7State of Louisiana Office of Group Benefits. CVS Caremark Prior Authorizations and Appeals Program
- Urgent pre-service appeal: 72 hours
- Non-urgent pre-service appeal: 15 days
- Post-service appeal: 30 days
If the first-level denial is upheld, you can request a second-level appeal within 180 days. At that stage, CVS Caremark has the case reviewed by a qualified medical reviewer who was not involved in the original decision. If the second-level appeal is also denied, the notification will explain how to request external review.
External Review
After internal appeals are exhausted, you have the right to an independent external review. This applies to any denial involving medical judgment, including situations where the plan calls a treatment experimental or investigational.8HealthCare.gov. External Review You must request external review in writing within four months of the final internal denial. You can appoint your doctor or another medical professional to file on your behalf. The federal process administered by HHS carries no charge; state-level external review processes may charge up to $25.
At every level, the strongest appeals include new clinical evidence the first submission lacked. Updated lab work, a detailed letter of medical necessity, or documentation of adverse reactions to the plan’s preferred alternatives give the appeal a far better chance than resubmitting the same paperwork that was denied.