CVS Caremark Prior Authorization (PA) tools are developed to ensure safe, effective and appropriate use of selected drugs. Health benefits and health insurance plans contain exclusions and limitations. You have options such as all major credit and debit cards, electronic check and more. affiliated with CVS Caremark. Type: Clinical . A physician will need to fill in the form with the patient’s medical information and submit it to CVS/Caremark for assessment. Prior Authorization can ensure proper patient selection, dosage, drug administration and duration of selected drugs.When a PA is needed for a prescription, the member will be asked to have the physician or authorized agent of the physician contact our Prior Authorization Department to answer criteria questions to determine coverage. We would like to show you a description here but the site won’t allow us. Aetna Better Health of Texas is not responsible or liable for non-Aetna Better Health content, accuracy, or privacy practices of linked sites, or for products or services described on these sites. Download it now:Refill prescriptions (mail service only) without creating an account.Download a form to start a new mail order prescription. Applications and forms for health care professionals and their patientsTo change your phone or fax number, email address or practice address, use the link below. Links to various Aetna Better Health and non-Aetna Better Health sites are provided for your convenience. Each insurer has sole financial responsibility for its own products. Or by completing this form: Mail Service Order Form Mail Service Order Form (Spanish) CVS Caremark Mail Service Pharmacy PO BOX 94467 PALATINE, IL 60094-4467 Let us know how you want to pay for your order. Complete/review information, sign and date. If your changes result from an out-of-state move or a change of provider group, please use the form above instead.For Part D prior authorization forms, please see the Medicare section.If your're retiring, moving out of state or changing provider groups, use this form to notify us. 1 Does PRIOR AUTHORIZATION CRITERIA BRAND NAME: (Generic) HUMIRA (adalimumab) Status: Client Requested Criteria . Prior Authorization can ensure proper patient selection, dosage, drug administration and duration of selected drugs. ... For Part D prior authorization forms, please see the Medicare section. CVS Caremark Mail Service Pharmacy and Aetna are part of the CVS Health family of companies.

Our PA criteria are:*May not result in near real-time decisions for all prior authorization types and reasons.The CVS/caremark™ app lets you manage your prescription benefits on the go. The CVS/Caremark prior authorization form is to be used by a medical office when requesting coverage for a CVS/Caremark plan member’s prescription. Prior Authorization Form Ciclopirox Topical Solution 8% This fax machine is located in a secure location as required by HIPAA regulations. That way you can avoid processing delays. Lower Limb Prosthesis including Microprocessor-Controlled KneeGeneral prescription drug coverage determination (through SilverScript)Zolpidem tartrate (generic Ambien® immediate release)Adcetris® (Brentuximab Vedotin) Injectable Medication Precertification Request Alpha 1 Antitrypsin Inhibitor Therapy Precertification RequestAvastin™ (bevacizumab) Mvasi™ (bevacizumab-awwb) Zirabev™ (bevacizumab-bvzr) Medication Precertification RequestBavencio®(Avelumab) Medication Precertification RequestBenlysta®(Belimumab) Injectable Medication Precertification RequestBerinert® (C1 esterase inhibitor, human) Medication Precertification RequestBesponsa®(Inotuzumab Ozogamicin) Medication Precertification RequestCinqair® (Reslizumab) Medication Precertification RequestCinryze® (C1 esterase inhibitor, human) Medication Precertification RequestCrysvita® (burosumab-twza) Injectable Medication Precertification RequestCyramza® (Ramucirumab) Medication Precertification RequestDarzalex™ (Daratumumab) Medication Precertification RequestEmend® (Fosaprepitant) Injectable Medication Precertification RequestEmpliciti™ (Elotuzumab) Medication Precertification RequestEnhertu® (fam-trastuzumab deruxtecan-nxki) Medication Precertification RequestErbitux® (Cetuximab) Injectable medication precertification RequestErythropoiesis Stimulating Agents (ESAs) Medications/Dialysis MedicareExondys51® (Eteplirsen) Injectable Precertification RequestFasenra™ (Benralizumab) Injectable Medication Precertification RequestGattex® (Teduglutide) Injectable Medication Precertification RequestGazyva® (Obinutuzumab) Injectable Medication Precertification RequestGilenya® (Fingolimod) Medication Precertification RequestGilvaari™ (givosiran) Medication Precertification RequestHerceptin ® (Trastuzumab), Kadcyla ® (Ado-Trastuzumab) and Perjeta ® (Pertuzumab) Medicare Ilaris® (Canakinumab) Injectable Medication Precertification Request Imfinzi® (Durvalumab) Injectable Medication Precertification RequestImlygic™ (Talimogene Laherparepvec) Medication Precertification RequestKalbitor® (ecallantide) Medication Precertification RequestKeytruda®(Pembrolizumab) Injectable Medication Precertification RequestLartruvo™ (Olaratumab) Medication Precertification RequestLeukine® (sargramostim) Medication Precertification RequestLevoleucovorin (Fusilev®, Khapzory™) Injectable Medication Precertification RequestLibtayo® (cemiplimab) Medication Precertification RequestLumoxiti™ (moxetumomab pasudotox)) Medication Precertification RequestLuxturna ® (Voretigene Neparvovec-rzyl) Medication Precertification RequestMacugen® (Pegaptanib Sodium) Injectable Medication Precertification RequestMakena® (Hydroxyprogesterone Caproate) Medication Precertification RequestNucala® (Mepolizumab) Injectable Medication Precertification Request  Onpattro® (patisiran) Injectable Medication Precertification RequestOpdivo® (Nivolumab) Injectable Medication Precertification RequestPadcev™ (enfortumab vedotin-ejfv) Medication Precertification RequestParsabiv™ (Etelcalcetid) Medication Precertification RequestRadicava™ (Edaravone) Medication Precertification RequestReblozyl® (luspatercept-aamt) Medication Precertification RequestPulmonary Arterial Hypertension (Infusible, Inhalation, or Injectable Medication) MedicareRuconest® (C1 esterase inhibitor, recombinant) Medication Precertification RequestSandostatin® LAR (octreotide acetate) Medication Precertification RequestSarclisa® (isatuximab-irfc) Medication Precertification RequestSimponi Aria® (Golimumab) Infusion Medication Precertification RequestSoliris® (Eculizumab) Medication Precertification RequestSomatuline Depot® (lanreotide) Medication Precertification RequestSpinzara® (Nusinersen) Injectable Precertification RequestSpravato™ (esketamine) Medication Precertification RequestTakhzyro® (C1 esterase inhibitor, recombinant) Medication Precertification RequestTecentriq™ (Atezolizumab) Medication Precertification RequestTegsedi™ (inotersen) Medication Precertification RequestTepezza™ (teprotumumab-trbw) Medication Precertification RequestTremfya® (Guselkumab) Medication Precertification RequestUdenyca™ (pegfilgrastim-cbqv) Precertification RequestUltomiris™ (ravulizumab-cwvz) Precertification RequestVectibix® (Panitumumab) Injectable medication precertification RequestVyepti™ (eptinezumab-jjmr) Medication Precertification RequestVyondys 53® (golodirsen) Injectable Medication Precertification RequestXofigo® (Radium-223 dichloride) Injectable Medication Precertification RequestYervoy® (Ipilimumab) Injectable Medication Precertification RequestZarxio® (filgrastim-sndz) Medication Precertification RequestZoladex® (goserelin acetate) Medication Precertification RequestZulresso™ (brexanolone) Medication Precertification RequestRheumatoid/Psoriatic/Juvenile Arthritis and Ankylosing Spondylitis Medication RequestAlpha 1 Antitrypsin Inhibitor Therapy Precertification RequestEmpliciti™ (Elotuzumab) Medication Precertification RequestFasenra™ (Benralizumab) Injectable Medication Precertification RequestFeraheme® (ferumoxytol) and Injectafer® (ferric carboxymaltose) Medication Precertification RequestFulphila™ (pegfilgrastim-jmdb) Medication Precertification RequestH.P Acthar Gel (Repository Corticotropin) Medication Precertification RequestHyaluronates (Viscosupplementation) Injectable Medication Precertification RequestImlygic™ (Talimogene Laherparepvec) Medication Precertification RequestImmune Globulin (IG) Therapy Medication Precertification RequestInfertility Medication Precertification Request (Female)Infertility Medication Precertification Request (Male) Jelmyto™ (mitomycin) Medication Precertification RequestLartruvo™ (Olaratumab) Medication Precertification RequestLumoxiti™ (moxetumomab pasudotox)) Medication Precertification RequestNivestym™ (filgrastim-aafi) Precertification RequestOntruzant® (trastuzumab-dttb) Medication Precertification RequestParsabiv™ (Etelcalcetid) Medication Precertification RequestRadicava™ (Edaravone) Medication Precertification RequestSpravato™ (esketamine) Medication Precertification RequestTecentriq™ (Atezolizumab) Medication Precertification RequestTegsedi™ (inotersen) Medication Precertification RequestUdenyca™ (pegfilgrastim-cbqv) Precertification RequestUltomiris™ (ravulizumab-cwvz) Precertification RequestNew Hampshire Prescription Drug Prior AuthorizationTexas Telemedicine and Telehealth Services Reimbursement PolicyDo you have Aetna insurance through an employer or are you a Medicare member?