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MemberName:{{MEMFIRST}}{{MEMLAST}}DOB:{{MEMBERDOB}}PANumber:{{PANUMBER}} Sendcompletedformto:CaseReviewUnitCVSCaremarkPriorAuthorizationFax:1-866-249-6155All Plans Phone: 866-814-5506 Fax: 866-249-6155 Non-Specialty Medications : MassHealth Phone: 877-433-7643 Fax: 866-255-7569 Commercial Phone: 800-294-5979 Fax: 888-836-0730 Exchange Phone: 855-582-2022 Fax: 855-245-2134 . Medical Specialty Medications (NLX) All Plans Phone: 844-345-2803 Fax: 844-851-0882 . Exceptions. Overview . …Phone: 1-866-814-5506 Fax: 1-866-249-6155 www.caremark.com Page 1 of NUMPAGES 3 Otezla Prior Authorization Request CVS Caremark administers the prescription benefit plan for the patient identified. This patient’s benefit plan requires prior authorization for certain medications in order for the drug to be covered. MemberName:{{MEMFIRST}}{{MEMLAST}}DOB:{{MEMBERDOB}}PANumber:{{PANUMBER}} Sendcompletedformto:CaseReviewUnitCVSCaremarkPriorAuthorizationFax:1-866-249-6155

All Plans Phone: 866-814-5506 Fax: 866-249-6155 . Non-Specialty Medications . MassHealth Phone: 877-433-7643 Fax: 866-255-7569 Commercial Phone: 800-294-5979 Fax: 888-836-0730 Exchange Phone: 855-582-2022 Fax: 855-245-2134 . Medical Specialty Medications (NLX) All Plans Phone: 844-345-2803 Fax: 844-851-0882 .

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Phone: 1-866-814-5506 Fax: 1-866-249-6155 www.caremark.com Page 1 of 2 Epogen, Procrit, Retacrit Prior Authorization Request CVS Caremark administers the prescription benefit plan for the patient identified. This patient’s benefit plan requires prior authorization for certain medications in order for the drug to be covered.

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MemberName:{{MEMFIRST}}{{MEMLAST}}DOB:{{MEMBERDOB}}PANumber:{{PANUMBER}} Sendcompletedformto:CaseReviewUnitCVSCaremarkPriorAuthorizationFax:1-866-249-6155All Plans Phone: 866-814-5506 Fax: 866-249-6155 . Non-Specialty Medications . MassHealth Phone: 877-433-7643 Fax: 866-255-7569 Commercial Phone: 800-294-5979 Fax: 888-836-0730 Exchange Phone: 855-582-2022 Fax: 855-245-2134 . Medical Specialty Medications (NLX) All Plans Phone: 844-345-2803 Fax: 844-851-0882 . Exceptions. N/A …Phone: 1-855-344-0930. Fax: 1-855-633-7673. If you wish to request a Medicare Part Determination (Prior Authorization or Exception request), please see your plan's website for the appropriate form and instructions on how to submit your request. Phone: 1-877-433-7643.Phone: 1-866-814-5506 Fax: 1-866-249-6155 www.caremark.com Page 1 of 4 Lupron Hormonal Therapy Prior Authorization Request CVS Caremark administers the prescription benefit plan for the patient identified. This patient’s benefit plan requires prior authorization for certain medications in order for the drug to be covered.All Plans Phone: 866-814-5506 Fax: 866-249-6155 ... 866-255-7569 Commercial Phone: 800-294-5979 Fax: 888-836-0730 Exchange Phone: 855-582-2022 Fax: 855-245-2134 Medical Specialty Medications (NLX) All Plans Phone: 844-345-2803 Fax: 844-851-0882 Exceptions N/A Overview These criteria were developed to meet state-specific regulatory …All Plans Phone: 866-814-5506 Fax: 866-249-6155 ... 877-433-7643 Fax: 866-255-7569 Commercial Phone: 800-294-5979 Fax: 888-836-0730 Exchange Phone: 855-582-2022 Fax: 855-245-2134 . Medical Specialty Medications (NLX) All Plans Phone: 844-345-2803 Fax: 844-851-0882 . Exceptions. N/A . Overview . Denosumab is a type of monoclonal …All Plans Phone: 866-814-5506 Fax: 866-249-6155 . ... 866-255-7569 Commercial Phone: 800-294-5979 Fax: 888-836-0730 Exchange Phone: 855-582-2022 Fax: 855-245-2134 . Medical Specialty Medications (NLX) All Plans Phone: 844-345-2803 Fax: 844-851-0882 . Exceptions. Cinqair, Fasenra, Nucala and Xolair solutions are Medical Benefit only . …

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Phone: 1-866-814-5506 Fax: 1-866-249-6155 www.caremark.com Page 1 of 3 Tremfya Prior Authorization Request CVS Caremark administers the prescription benefit plan for the patient identified. This patient’s benefit plan requires prior authorization for certain medications in order for the drug to be covered.Ask your doctor to send your prescription to CVS Specialty. Your doctor can e-prescribe, call 1‑800‑237-2767 or fax your prescription to 1-800-323-2445.Specialty Medication PA Request Phone: (866) 814-5506. Nonspecialty Medication PA Request Phone: (877) 433-7643 (Medicaid), (855) 582-2022 (Exchange),. (800) ...Medical specialty and pharmacy policies. IMPORTANT COVID-19 INFORMATION: During the COVID-19 public health emergency, some of our medical specialty and pharmacy policies may be superseded by the information on our COVID-19 FAQ. For Commercial. For MassHealth. CVS Caremark is dedicated to helping physicians manage and help their patients who are suffering from complex disorders and require specialized therapies and personalized care.Phone: 1-866-814-5506 Fax: 1-866-249-6155 www.caremark.com Page 2 of 3 Note: This fax may contain medical information that is privileged and confidential and is solely for the use of individuals named above. Prior Authorization Form for Medical Procedures, Courses of Treatment, or Prescription Drug Benefits. If you have questions about our prior authorization requirements, please …For specialty drug prior authorization review, your doctorshould call CVS Caremark toll-free at 1-866-814-5506 before you go to the pharmacy. The prior authorization line is for your doctor’s use only. All Plans Phone: 866-814-5506 Fax: 866-249-6155 . Non-Specialty Medications . MassHealth Phone: 877-433-7643 Fax: 866-255-7569 Commercial Phone: 800-294-5979 Fax: 888-836-0730 Exchange Phone: 855-582-2022 Fax: 855-245-2134 . Medical Specialty Medications (NLX) All Plans Phone: 844-345-2803 Fax: 844-851-0882 . Exceptions. …Phone: 1-866-814-5506 Fax: 1-855-330-1720 www.caremark.com Page 1 of 3. Reclast. Prior Authorization Request. Send completed form to: Case Review Unit CVS Caremark Specialty Programs Fax: 1-855-330-1720. CVS Caremark administers the prescription benefit plan for the patient identified.

Specialty medication—Call the authorization line at 1-866-814-5506; Return to top. Dental Insurance Coverage. Dental insurance is available to eligible full-time employees, faculty members and their eligible dependents. The plan may vary by job classification and whether the position is represented and covered by a collective bargaining agreement. Dental Plans.

All Plans Phone: 866-814-5506 Fax: 866-249-6155 . Non-Specialty Medications . MassHealth Phone: 877-433-7643 Fax: 866-255-7569 Commercial Phone: 800-294-5979 Fax: 888-836-0730 Exchange Phone: 855-582-2022 Fax: 855-245-2134 . Medical Specialty Medications (NLX) All Plans Phone: 844-345-2803 Fax: 844-851-0882 . Exceptions. N/A …

Phone: 1-866-814-5506 Fax: 1-866-249-6155 www.caremark.com Page 1 of 4 Cosentyx Prior Authorization Request CVS Caremark administers the prescription benefit plan for the patient identified. This patient’s benefit plan requires prior authorization for certain medications in order for the drug to be covered. All Plans Phone: 866-814-5506 Fax: 866-249-6155 Non-Specialty Medications : MassHealth Phone: 877-433-7643 Fax: 866-255-7569 Commercial Phone: 800-294-5979 Fax: 888-836-0730 Exchange Phone: 855-582-2022 Fax: 855-245-2134 . Medical Specialty Medications (NLX) All Plans Phone: 844-345-2803 Fax: 844-851-0882 . Exceptions. N/A . Overview . …Phone: 1-866-814-5506 Fax: 1-866-249-6155 www.caremark.com Page 1 of 4 Doptelet Prior Authorization Request CVS Caremark administers the prescription benefit plan for the patient identified. This patient’s benefit plan requires prior authorization for certain medications in order for the drug to be covered.All Plans Phone: 866-814-5506 Fax: 866-249-6155 Non-Specialty Medications . MassHealth Phone: 877-433-7643 Fax: 866-255-7569 Commercial Phone: 800-294-5979 Fax: 888-836-0730 Exchange Phone: 855-582-2022 Fax: 855-245-2134 Medical Specialty Medications (NLX) All Plans Phone: 844-345-2803 Fax: 844-851-0882 . Exceptions. Kalbitor is only …PHONE 844-556-2925 Provider Enrollment & Credentialing EMAIL [email protected] FAX 617-526-1982 Provider Service PHONE 855-444-4647 Monday through Friday 8:00 a.m. to 6:00 p.m. EMAIL [email protected] Aetna Signature Administrators (Aetna HealthSCOPE) Provider Service PHONE 800-603-96471-866-814-5506. For inquiries or questions related to the patient’s eligibility, drug copay or medication delivery; please contact the Specialty Customer Care Team: CaremarkConnect ® 1-800-237-2767. The recipient of this fax may make a request to opt-out of receiving telemarketing fax transmissions from CVS Caremark. There are numerousAll Plans Phone: 866-814-5506 Fax: 866-249-6155 . Non-Specialty Medications . MassHealth Phone: 877-433-7643 Fax: 866-255-7569 Commercial Phone: 800-294-5979 Fax: 888-836-0730 Exchange Phone: 855-582-2022 Fax: 855-245-2134 . Medical Specialty Medications (NLX) All Plans Phone: 844-345-2803 Fax: 844-851-0882 . Exceptions. N/A …Phone: 1-808-254-4414 Fax: 1-866-237-5512 www.caremark.com Page 3 of 7 105. Is the patient’s asthma inadequately controlled with the use of a long acting beta agonist at the optimized dose? Action Required: Attach documentation of current medications (including doses) from the medical record Yes, Continue to #1061 Jan 2023 ... Prescribers may call 1-866-814-5506 to request SGM review. The Funds may choose to modify this list prior to the next quarterly publication ...If you have questions regarding the prior authorization, please contact CVS Caremark at 1-866-814-5506. For inquiries or questions related to the patient's eligibility, drug copay or medication delivery; please contact the Specialty Customer Care Team: CaremarkConnect® 1-800-237-2767.Phone:1-866-814-5506 Fax:1-866-249-6155 www.caremark.com Page4of4 SectionE:PsoriaticArthritis Continuation 30 ...

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