Certain prescription drugs require prior approval. The prescribing provider must contact CVS Caremark at 800-294-5979 for prior authorization. The provider must provide appropriate documentation of medical necessity.
Only the provider can request prior authorization approval. Examples of prescription drugs requiring prior authorization include, but are not limited to, medications for treating acne, androgens and anabolic steroids, growth hormones, and medications for treating Hepatitis B and C. The quantity of some prescription drugs may be limited based on drug indications or medical necessity. If the quantity of a covered prescription drug, as prescribed by the provider, is not approved by CVS Caremark, the provider must contact CVS Caremark for prior approval of additional quantities. Approval will require appropriate documentation of medical necessity. The fact that a provider has prescribed, ordered, recommended or approved a prescription drug, does not, in itself, make the prescription drug medically necessary for purposes of coverage under the Plan.
Step Therapy
Some prescription drugs require step therapy. Step therapy is a process that optimizes rational drug therapy while controlling costs by defining how and when a particular drug or drug class should be used based on a patient's drug history. Step therapy requires the use of one or more prerequisite drugs that meet specific conditions before the use of another drug or drugs.