Medicare Advantage Prior Authorization Fax Form (CVS Caremark specialty medications)
A prior authorization request form used by HMSA Medicare Advantage members whose prescription benefit is administered by CVS Caremark; gathers patient, prescriber, diagnosis, site of care, and condition-specific checklist information to support coverage determinations for specialty medications (examples listed include Actemra and others).
No material clinical/coverage changes for this administrative form.
Policy overview
This is a CVS Caremark prior authorization fax form used for HMSA Medicare Advantage specialty medications; CVS Caremark administers the prescription benefit and requests that the completed form be faxed to CVS Caremark at 1-866-237-5512. For questions on prior authorization contact CVS Caremark at 1-808-254-4414, and for eligibility, copay, or medication delivery inquiries contact the Specialty Customer Care Team, CaremarkConnect® 1-800-237-2767.