Prior authorization to CVS Caremark required

Prior authorization to CVS Caremark Specialty Programs is required for botulinum toxin products; send the completed specialty prior authorization form via fax to CVS Caremark Specialty Programs (Fax: 1-866-237-5512) or contact CVS Caremark with questions at 1-808-254-4414.

• Approvals may be subject to dosing limits per FDA labeling and accepted guidelines (see form).
• Provide the most accurate diagnosis for the prescribed medication on the form.

Use listed ICD-10 codes to support medical necessity

Use the ICD-10 diagnosis codes listed in the policy (Appendix C and Table 2) to support medical necessity on the CVS Caremark specialty form; the document includes CVS Caremark Specialty Programs contact information for submission and clarification.

• Appendix C and Table 2 ICD-10 codes serve as supporting diagnoses for coverage determinations.
• Provide accurate ICD-10 codes on the faxed prior authorization form.

Submit prior authorization to CVS Caremark Specialty Programs

Submit prior authorization requests and the completed specialty form to CVS Caremark Specialty Programs using the provided fax and address; the preferred submission method is fax to 1-866-237-5512.

• Mailing address for CVS Caremark Specialty Programs: 2969 Mapunapuna Place, Honolulu, HI 96819 (shown on form).
• Phone for questions: 1-808-254-4414.

Include thoracic spinal cord codes and required secondary code

When using thoracic spinal cord diagnosis codes, include the required paired secondary diagnosis code from the referenced table on the submission; incomplete code pairing may render the request incomplete.

• Thoracic spinal cord codes listed (e.g., S24.133A, S24.134A, S24.141A, S24.142A, S24.144A, S24.151A, S24.152A, etc.) must be accompanied by a second code from the Table 2 secondary diagnosis list.
• The policy states: 'The diagnosis codes above require a second code from Table in order to be' complete.

Preferred products (Dysport, Xeomin) required first; document exceptions

If a non-preferred botulinum product is requested, the form requires that preferred products (Dysport and Xeomin) be considered first; exceptions require documentation of inadequate response or intolerable adverse event to the preferred products.

• Question C on the form identifies Dysport and Xeomin as the preferred products and asks if the patient's treatment can be switched to a preferred product.
• Exception logic (Questions F, K, N, P) requires attaching supporting chart note(s) documenting inadequate response or intolerable adverse events to preferred products when requesting a non-preferred product.

Send completed form to CVS Caremark (fax/address)

Send the completed specialty prior authorization form and supporting documentation to CVS Caremark Specialty Programs via fax; the form and confidentiality notice are provided on the document.

• Fax: 1-866-237-5512
• Address: CVS Caremark Specialty Programs, 2969 Mapunapuna Place, Honolulu, HI 96819

Attach chart notes documenting failure/intolerance to preferred products

Ensure the submission includes any required supporting chart notes when exception criteria are invoked; attach documentation of prior inadequate response or intolerable adverse events to preferred products as indicated on the form.

• Action required: If the patient had inadequate response or intolerable adverse events to preferred products, 'Attach supporting chart note(s).' (see Questions F, K, N, P).
• Supporting notes should be included with the faxed prior authorization form.

Use provided CVS Caremark contact and observe confidentiality notice

Use the CVS Caremark Specialty Programs submission contact details shown on the form for all prior authorization communications; the fax may contain privileged information and includes a confidentiality notice.

• Fax: 1-866-237-5512; Phone: 1-808-254-4414; Website: caremark.com
• Confidentiality notice on fax: privileged/ confidential medical information instructions for unintended recipients.

Fax completed prior authorization form to CVS Caremark

Send the completed prior authorization form via fax to CVS Caremark Specialty Programs at 1-866-237-5512; include all supporting documentation and ensure required diagnosis coding is present.

• Include the most accurate diagnosis and required secondary codes where applicable.
• Keep copies of documentation; the fax includes directions for inadvertent receipt.

Include required paired diagnosis coding with submissions

Completed prior authorization form and supporting documentation should be sent to CVS Caremark Specialty Programs (Fax: 1-866-237-5512); ensure that the submission includes paired diagnosis coding when required by the policy.

• The policy explicitly states the diagnosis codes above require a second code from Table 2 to be complete.
• Submissions lacking required secondary diagnosis codes may be considered incomplete.

Denial risk if no prior authorization or if indication is cosmetic/Appendix D

Requests may be denied if prior authorization is not obtained, or if the requested use is for a cosmetic indication or an Appendix D–listed condition; obtain authorization and ensure indication is not excluded.

• Clinical Criteria Question 1 directs denial of further questions if botulinum toxin is prescribed for a cosmetic indication or any condition/ICD-10 listed in Appendix D.
• Appendix D lists multiple conditions for which botulinum toxin therapy is NOT reasonable and necessary.

Use paired primary + secondary ICD-10 codes where specified

Certain ICD-10 diagnosis codes in Table 2 must be used as a paired primary and secondary code on the prior authorization form; confirm both codes are present before submission.

• The form states: 'The following ICD-10 codes must be used in pairs, i.e., one primary diagnosis and one secondary diagnosis.'
• Table 2 lists primary codes that 'Require a Secondary ICD-10 Code for Payment.'

Missing required secondary code may cause denial

Omitting a required secondary diagnosis code for Table 2 primary codes may trigger denial; ensure the secondary code from the specified list is included with the primary code on the submission.

• Policy note: 'The diagnosis codes above require a second code from Table in order to be' complete.
• The submission instructions repeatedly emphasize inclusion of both codes.

Exclusions in Appendix D may trigger denial

Requests for botulinum toxin therapy for conditions listed in Appendix D are considered not reasonable and necessary and may be denied; do not submit authorization requests for these excluded indications.

• Appendix D exclusions include: strabismus and deviations over 50 prism diopters; restrictive strabismus; chronic paralytic strabismus (with limited exceptions); Duane's syndrome with lateral rectus weakness; recurrent TMJ disorder; anal spasm; irritable colon; biliary dyskinesia; muscle tension/tension headaches; myofascial pain; other smooth muscle spasms not listed as covered; and spastic conditions not listed as covered.