Non-Formulary Marketplace Exception Prior Authorization
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Form used to request prior authorization for non-formulary medications (Marketplace HMF) for Oscar Health members; completed by prescribing provider and faxed to CVS/Caremark for review and approval.
No material clinical or coverage changes in this revision.
Coverage Criteria
Authorization criteria
Covered when ALL of the following are met and documentation provided:
Fax to 1-855-245-2134; contact CVS/Caremark at 1-855-582-2022 for prior authorization process.
Provider must circle 'Y' on form to indicate compliance and supply supporting documentation as applicable.
Provider must answer question 3 on form and supply trial documentation.
When no/formulary alternatives not appropriate
- No formulary alternative or alternatives not recommended: 4) If no formulary alternative exists or listed alternatives are not recommended based on published guidelines or clinical literature, provide documentation of the clinical condition supporting use of the non‑formulary agent.
Provider must answer question 4 on form and include clinical documentation.
- Specific dosage form required: 5) If a specific non‑formulary dosage form is required (examples: suspension, solution, injection) and not available as a formulary alternative, provide rationale and documentation.
Provider must answer question 5 on form and include rationale/documentation.
Provider must answer question 6 on form and include dosing documentation (package insert, AHFS, Micromedex, or accepted guidelines).
Signature required on submitted form.
None explicitly listed on the Non-Formulary Marketplace Exception form.
Requests that do not include the required supporting documentation or that fail to meet the trial/dosing criteria described on the form may not be approved. The form requires documentation of prior medication trials (names, dates, and reasons for failure/intolerance/contraindication) when formulary alternatives exist, justification when no formulary alternative is appropriate, and dosing details when requested quantity/dosing falls outside initial limits; failure to provide this information implies the request does not meet the stated criteria.
Coding
| ICD Code | Requested diagnosis code — provider to supply |
Provider Actions & Submission Requirements
Prior Authorization Submission
Provider must complete and sign the Non-Formulary Marketplace Exception prior authorization form and fax it to CVS/Caremark for review at 1-855-245-2134. For questions about the prior authorization process, contact CVS/Caremark at 1-855-582-2022.
- Fax signed Non-Formulary Marketplace Exception form to CVS/Caremark: 1-855-245-2134
- Questions about prior authorization: CVS/Caremark 1-855-582-2022
Step therapy / Formulary Alternative Trials
If formulary alternatives exist, document failure, intolerance, or contraindication for required number of alternatives based on class size. Include medication names, dates of trials, and reasons for failure/intolerance/contraindication. The requirement is: 3 alternatives tried for a class with 3+ alternatives; 2 alternatives for a class with 2 alternatives; 1 alternative if only 1 exists.
- List each formulary alternative tried with start/end dates
- Provide clinical reason for failure, intolerance, or contraindication for each
- State class size and number of required trials
Required Supporting Documentation
Provide required supporting documentation to justify the non-formulary request. Documentation must include prior medication trials (name of medication(s), dates of trial(s), and reason for treatment failure(s), intolerance and/or contraindication), the clinical condition when no formulary alternative is appropriate, or the specific dosage form needed that is not available in formulary alternatives. For dosing exceptions, include medication name, quantity, strength, directions, and duration requested and confirm prescribed quantity falls within manufacturer's or compendia dosing guidelines.
- Medication name(s), trial dates, and documented reason(s) for failure/intolerance/contraindication
- Description of clinical condition if no formulary alternative is appropriate
- Specification of required dosage form (e.g., suspension, solution, injection) if applicable
- Dosing justification: name, quantity, strength, directions, duration, and source of dosing guideline (manufacturer insert, AHFS, Micromedex, guidelines)
Documentation-related Denials
Failure to provide required documentation or dosing justification may result in denial of the non-formulary exception request. Ensure the prescriber (or authorized representative) signs and dates the form.
- Unsigned or undated forms risk denial
- Incomplete medication trial details or missing reasons for failure/intolerance/contraindication may lead to denial
- Missing dosing documentation for quantity exceptions may lead to denial
Step Therapy Requirements
| Step | Requirement |
|---|---|
| 1 | |
| Number of required trials equals number of formulary alternatives in the therapeutic class as specified on the form: 3 alternatives = 3 trials; 2 alternatives = 2 trials; 1 alternative = 1 trial. Documentation of medications tried, dates, and reason for failure/intolerance/contraindication is required for approval. |
Definitions
Background
The Non-Formulary Marketplace Exception form is used by the prescribing provider to request prior authorization for a non-formulary medication when a member may need an exception due to lack of efficacy, intolerance, contraindication, a required dosage form not available on formulary, or when dosing/quantity requested is outside standard limits. The provider must complete and sign the form, attest to the screening questions about indication, formulary alternative trials, clinical justification, dosage form needs, and dosing conformity with manufacturer or compendia guidelines, and fax the signed form to CVS/Caremark for review at the number provided.
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