Formulary Exception / Prior Authorization Request Form
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Defines the process and required information for requesting a formulary exception, prior authorization, quantity limit override, or step therapy determination from CVS Caremark on behalf of CommunityCare members; applies to members, prescribers, or authorized designees seeking access to clinically appropriate drugs.
No material clinical or coverage changes in this revision.
Coverage criteria and acceptable justifications
Acceptable justification categories
Forms should include one or more of the following justifications:
Requester must provide supporting documentation as indicated on form (clinical notes, prior therapy, contraindications, adverse outcomes, stability rationale).
Form prompts these specific items under 'Alternate formulary drug(s) contraindicated or previously tried, but with adverse outcome'.
Form includes a prompt to describe anticipated significant adverse clinical outcome to support continuation.
The form itself does not enumerate specific clinical exclusion conditions. Rather, it captures reasons for requesting an exception or authorization (for example, non‑formulary drug, prior formulary removal, coverage under another insurer, prior authorization, step therapy, or exceeding a quantity limit) and relies on plan-level medical necessity rules to determine eligibility. Any clinical exclusions would be applied during review of the submitted clinical documentation and are not listed on the form.
The form does not define discrete "not medically necessary" scenarios. Determinations that a requested drug is not medically necessary will be made after review of the completed form and any attached clinical records, including diagnosis, prior therapy, adverse outcomes or contraindications, and other supporting documentation provided by the prescriber.
What providers or prescribers must submit
Prior Authorization / Formulary Exception Request
This form is to be used for requesting a drug formulary exception for medications that are not on Community-Care's formulary list or drugs that are on Community-Care's formulary list but require a utilization management decision (prior authorization, quantity limit or step therapy). It allows the member, the member's designee, or the member's prescribing physician (or other prescriber) permission to request and gain access to clinically appropriate drugs. All pages must be completed with accurate information. Your prescribing physician must also complete page 2 and attach the necessary clinical notes. You may also ask us for a formulary exception by phone.
- Submit the completed prior authorization or formulary exception request form to CVS Caremark Prior Authorization Department by fax: 855-245-2134 or call Toll Free: 844-233-2184 (TTY/TDD: 711). Include all required clinical documentation.
- Form may be used to request: formulary exception, prior authorization, step therapy exception, or quantity limit override.
Step Therapy Exception Requests
Step therapy exception requests must clearly indicate that a step therapy determination is being requested and provide the clinical rationale and prior treatment history demonstrating why the required step(s) are medically inappropriate for the patient.
- Include prior medications tried, dates, doses, and reason for discontinuation (lack of efficacy, intolerance, contraindication).
- Attach supporting medical records demonstrating failure or contraindication to required step therapy agents.
Required Documentation
All submissions must include complete pages of the form with the prescriber section fully completed and the prescriber's signature. Attach all relevant clinical notes and supporting records (e.g., office notes, diagnostic test results, prior therapy documentation). Incomplete or missing documentation may delay or prevent processing.
- Complete all pages, including Drug Information (Drug name, Strength, Quantity, Duration) and Diagnosis and Medical Information (medication, strength/route, frequency, start date, expected length of therapy, quantity, patient height/weight, drug allergies, diagnosis).
- Prescriber must complete page 2 and sign; include clinical notes showing medical necessity.
Incomplete Submission Risk
Incomplete submissions — such as missing fields, missing prescriber signature, or lack of clinical notes/supporting records — may prevent processing and result in denial or delay. Ensure all requested information is provided to avoid unnecessary appeals or resubmissions.
- Missing prescriber signature or incomplete Drug Information or Diagnosis and Medical Information sections risks non-processing.
- If additional information is needed, the request may be pended until requested records are received.
Continuation / medical necessity for ongoing non-formulary therapy
Continuation / Medical Necessity
Requests to continue a member on a non-formulary drug should document stability and clinical risk of change.
Form contains fields prompting current therapy start date, expected length of therapy, clinical notes, and a specific field to describe the anticipated adverse clinical outcome.
Step therapy requirements and exception process
| Requirement | Provider action / documentation |
|---|---|
| Drug subject to step therapy | |
| Indicate on the form that the drug requires a step therapy determination and provide clinical rationale and prior treatment history (document prior attempts, contraindications, or adverse outcomes to step agents). |
Requests to exceed quantity limits
Key definitions and process timeframe
Background and scope
This form is used to request access to medications that are non‑formulary or that are subject to utilization management — including requests for formulary exceptions, prior authorization, step therapy determinations, or requests to exceed a plan quantity limit. The requester must complete the form and attach the necessary clinical notes and supporting documentation that justify the exception or override (for example, prior treatment history, contraindications, adverse outcomes, or documentation of stability on current therapy).
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