Indication AcipHex (rabeprazole) GEHA Prior Authorization Criteria Form- 2017 Prior Authorization Form PROTON PUMP INHIBITORS (FA-PA) This fax machine is located in a secure location as required by HIPAA regulations
The prescribing provider must submit the information requested within two (2) business days of receiving Caremark's request
When your doctor writes a prescription, it's important that you're able to start taking your medication as soon as possible
If you continue using one of these drugs without prior approval for medical necessity, you may be required to pay the full cost
What drug is being prescribed? RYBELSUS (semaglutide) TRULICITY (dulaglutide) VICTOZA (liraglutide) GLUCOSE-DEPENDENT INSULINOTROPIC POLYPEPTIDE (GIP) RECEPTOR AND GLUCAGON-LIKE PEPTIDE-1 (GLP-1) RECEPTOR AGONIST: MOUNJARO (tirzepatide) Status: Client Requested Criteria Type: Initial Prior Authorization with Logic Ref # C25460-D Status: CVS Caremark Criteria Type: Post Limit Prior Authorization POLICY FDA-APPROVED INDICATIONS PPI Post Limit Policy 918-J, 169-J 09-2017 CVS Caremark is an independent company that provides pharmacy benefit management services to CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc
For questions about a prior authorization covered under the pharmacy benefit, please contact CVS Caremark* at 855-582-2038
DPP-4-dipeptidyl peptidase-4; SGLT-2=sodium-glucose co-transporter 2
(generic name, dosage form) (codeine sulfate tablets) (hydromorphone hydrochloride oral soln, suppositories, tablets) (levorphanol tartrate tablets) (meperidine hydrochloride oral soln, tablets) (morphine sulfate oral soln, oral soln concentrate, suppositories, tablets) DRUG CLASS PRIOR AUTHORIZATION CRITERIA GLUCAGON-LIKE PEPTIDE 1 (GLP-1) RECEPTOR AGONIST BRAND NAME (generic) OZEMPIC (semaglutide) Status: CVS Caremark® Criteria Type: Initial Prior Authorization with Quantity Limit POLICY FDA-APPROVED INDICATIONS Ozempic is indicated: **Post Limit PA required when daily quantity limit OR Maximum day supply of 90 units per 365 days is exceeded** All proton pump inhibitors are subject to prior authorization upon exceeding 90 units (cumulative) per 365 days or exceeding daily dosing limits
For example, we've created a smoother, quality-focused prior authorization days; 16
The Participating Group signed below hereby accepts and adopts as its own the criteria for use with Prior Authorization, as administered by CVS Caremark
Please contact CVS/Caremark at 1-855-240-0536 with questions regarding the prior authorization process
DRUG CLASS PROTON PUMP INHIBITORS
Some automated decisions may be communicated in less than 6 seconds! We've partnered with CoverMyMeds ® and Surescripts ®, making it easy for you to access electronic prior authorization (ePA) via the ePA vendor of your choice
GEHA Prior Authorization Criteria Form- 2017 Prior Authorization Form PROTON PUMP INHIBITORS (FA-PA) This fax machine is located in a secure location as required by HIPAA regulations
BRAND NAME (generic) ACIPHEX Protonix [package insert]
CVS Caremark Customer Care Correspondence PO Box 6590 Lee's Summit, MO 64064-6590
27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbidity such as hypertension Sign in or register to see if your Rx requires prior authorization
docx
Saxenda is indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in: Adult patients with an initial body mass index (BMI) of: 30 kg/m2 or greater (obese), or
Hyperinflation Products with significant cost inflation This document contains confidential and proprietary information of CVS Caremark and cannot be reproduced, distributed or printed without written LIMIT PRIOR AUTHORIZATION CRITERIA DRUG CLASS IMMEDIATE-RELEASE OPIOID ANALGESICS (BRAND AND GENERIC)* (generic name, dosage form) CVS Caremark Specialty Programs 2969 Mapunapuna Place Honolulu, HI 96819 Phone: 1-808-254-4414 Fax: 1-866-237-5512 www
BRAND NAME (generic) AMPHETAMINES: ADZENYS (ALL PRODUCTS) This document contains c onfidential and proprietary information of CVS Caremark and cannot be reproduced, distributed or printed without written CVS/Caremark at 888-836-0730
27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbid condition
CVS Caremark Specialty Programs 2969 Mapunapuna Place Honolulu, HI 96819 Phone: 1-808-254-4414 Fax: 1-866-237-5512 www
Find out what terms like formulary and prior authorization mean and how these requirements can affect your medication options
Max Quantity Limits: Limit the quantity of opioids prescribed to 90 MME/day
pantoprazole, DEXILANT, NEXIUM Atopic Dermatitis
caremark
Prior Authorization Rx Savings
or coinsurance without an authorization for medical necessity, depending on your plan
Once we reach your doctor and receive approval, it will take 7 to 10 business days for your medication to be delivered
Prior to initiating treatment, appropriate nail specimens for laboratory testing [potassium hydroxide (KOH) preparation, fungal culture, or nail biopsy] should be obtained to confirm the diagnosis of onychomycosis
This file is no longer available
Please contact CVS Caremark at 1-855-240-0536 with questions regarding the prior If additional information is required to process a non-urgent prior authorization request, Caremark will advise the prescribing provider of any information needed within (2) business days of receiving the request
Let CVS Caremark help you understand your plan requirements as well as which of your medications are covered and which may need prior authorization
Below is a list of medicines by drug class that will not be covered without a prior authorization for medical necessity
POLICY
PROTONIX® (pantoprazole) ZEGERID® (omeprazole/sodium bicarbonate) Policy: Note: The provision of physician samples does not guarantee coverage under the provisions of
Prior authorization applies only to patients ≤ 19 years of age
pharmaceutical manufacturers not affiliated with CVS Caremark
Qsymia is indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in: Adults with an initial body mass index (BMI) of: 30 kg/m2 or greater (obese), or
For immediate processing, simply submit a prescription using your ePrescribing tool
GIP-GLP-1 Agonist Mounjaro PA with Limit Policy 5467-C, 5468-C UDR 05-2023
27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbid condition (e
Please contact CVS/Caremark at 800-294-5979 with questions regarding the prior authorization process
Wegovy is indicated as an adjunct to a reduced calorie diet and increased physical activity for chronic weight management in: adults with an initial body mass index (BMI) of: 30 kg/m2 or greater (obesity) or
Allow members, who have met certain Adlyxin
CVS Caremark Specialty Programs 2969 Mapunapuna Place Honolulu, HI 96819 Phone: 1-808-254-4414 Fax: 1-866-237-5512 www
Find out what terms like formulary and prior authorization mean and how these requirements can affect your medication options
NSAIDs, a component of Duexis and Vimovo, cause an increased risk of serious cardiovascular thrombotic events
AcipHex Actonel Alsuma Arthrotec Atacand Atacand HCT Atelvia Axert Beconase AQ Benicar Benicar
For questions about a prior authorization covered under the pharmacy benefit, please contact CVS Caremark* at 855-582-2038
All recommended doses throughout the labeling are based upon omeprazole
Check Drug Cost & Coverage
Coadministration with other tirzepatide-containing products or with any glucagon-like peptide-1 (GLP-1) receptor agonist is not recommended