[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-287992-105":53,"doc-detail-287992-en":126},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":119,"head_meta":121,"extra_data":123,"updated_unix":125},105,"en","cvs-caremark-prior-authorizations-and-appeals-program-prior-authorization-pa-program-appeals-program","CVS Caremark Prior Authorizations and Appeals Program - Prior Authorization (PA) Program - Appeals Program","","Explains how CVS Caremark initiates and evaluates Prior Authorization (PA) requests, including multiple submission routes (phone, fax, electronic request, or written contact by the prescribing physician or representative). Covers urgent and non-urgent PA processing timelines, the basis for clinical review using client-approved criteria, and outcomes including approval overrides or denial letters with appeal instructions. Details appeal rights, submission deadlines, and decision timelines for urgent and non-urgent pre-service and post-service appeals, including first- and second-level reviews and the path to external review.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":41,"@type":70,"position":76},"https://docshare.wps.com/template/letters/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/cvs-caremark-prior-authorizations-and-appeals-program-prior-authorization-pa-program-appeals-program/287992/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/cvs-caremark-prior-authorizations-and-appeals-program-prior-authorization-pa-program-appeals-program/287992.png","ImageObject",442,249,{"name":88,"@type":89},"Emma Wilson","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-23","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":9},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"How can a member or physician start a Prior Authorization (PA) request with CVS Caremark?","Question",{"text":108,"@type":109},"A PA can be initiated by phone call, fax, electronic request, or in writing to CVS Caremark by the prescribing physician or representative. A member can also call the Customer Care number on the back of the pharmacy benefits card, and a pharmacist can call the PA department to contact the prescriber for needed information.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What are the timeframes for CVS Caremark to process urgent and non-urgent PA requests?",{"text":113,"@type":109},"Urgent requests are processed within 2 business days from receipt. Non-urgent requests are processed within 72 hours from receipt. After approval, override and notifications are sent to the physician and member.",{"name":115,"@type":106,"acceptedAnswer":116},"What deadlines and timelines apply to appeal requests?",{"text":117,"@type":109},"Appeal requests must be received within 180 days of the adverse determination letter. Urgent pre-service appeals are completed within 72 hours; non-urgent pre-service appeals use plan-specific two-level timelines of 15 days per level, and post-service appeals are completed within 30 days. Second-level appeals also must be received within 180 days for review and potential external review.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},287992,1790186160,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":40,"category_name":41,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":76,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":76,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":9},3848291630094,"https://eur-avatar.wpscdn.com/davatar_085a072bc5b1113ac321206ff7593b45","CVS Caremark Prior Authorizations and Appeals Program Prior Authorization (PA) Program  \nIf a prescription requires a PA, there are multiple ways to start the PA process. A PA may be initiated by phone call, fax, electronic request or in writing to CVS Caremark by a member’s prescribing physician or his/her representative. A member may initiate a PA by calling the Customer Care number on the back of their pharmacy benefits card. A pharmacist may initiate a PA by calling the PA department, who will reach out to the prescribing physician to obtain the necessary information, or they will be instructed to have the member’s physician or designated representative contact CVS Caremark directly. The PA request is evaluated using client-approved criteria. A decision will be made solely on the clinical information available at the time of the review. PAs are processed within the following timeframes:  \n• Urgent requests from the member’s physician are processed within 2 business days from receipt of the request.  \n• Non-urgent requests are processed within 72 hours from receipt of the request. If the PA is approved, CVS Caremark will enter an override and approval notifications are generated and faxed to the physician and mailed to the member.  \nIf the PA does not meet the criteria requirements as required by the plan, the appropriate clinical reviewer will deny the PA request. Denial letters are generated and faxed to the physician and mailed to the member. Denial letters include directions on how to appeal the denial.  \nAppeals Program  \nOnce a member or member’s representative is notified that a claim is wholly or partially denied (an adverse determination), he or she has the right to appeal. Appeal requests must be received within 180 days of receipt of the adverse determination letter.  \nOnce an appeal is received, the appeal and all supporting documentation are reviewed and completed, including a notification to the member and physician, within the following timelines:  \n• Urgent Pre-Service Appeal: 72 hours  \n• Non-Urgent Pre-Service Appeal:  \n• For plans with two levels of appeal: 15 days for each level of appeal  \n• Post-Service Appeal: 30 days  \nOnce the first-level appeal is received, it will be reviewed with the supporting information provided and decisioned within the timeframes listed above. The member and the physician will be notified of the decision and if the denial is upheld, they will be provided information on how to request a second-level  \nappeal. The request for a second-level appeal must be received within 180 days of receipt of the adverse determination letter.  \nOnce a second-level appeal is received, it will be reviewed with the supporting information provided and reviewed for medical necessity with an appropriately qualified reviewer. The member and the physician will be notified of the decision and if the denial is upheld, they will be provided information on how to request an external review by an independent reviewer.  \nContact Us  \nFor information about a specific Prior Authorization or Appeals claim, please call the Customer Care phone number found on the back of your prescription benefits card.","cbCaicZ0iMRcYSfY","https://ap.wps.com/l/cbCaicZ0iMRcYSfY","pdf",266484,"English","# Prior Authorization (PA) Program\n## Initiating the PA process\n## PA evaluation and decision timelines\n# Appeals Program\n## Appeal submission deadlines and timelines\n## First- and second-level appeals and outcomes\n# Contact Us","[{\"question\":\"How can a member or physician start a Prior Authorization (PA) request with CVS Caremark?\",\"answer\":\"A PA can be initiated by phone call, fax, electronic request, or in writing to CVS Caremark by the prescribing physician or representative. A member can also call the Customer Care number on the back of the pharmacy benefits card, and a pharmacist can call the PA department to contact the prescriber for needed information.\"},{\"question\":\"What are the timeframes for CVS Caremark to process urgent and non-urgent PA requests?\",\"answer\":\"Urgent requests are processed within 2 business days from receipt. Non-urgent requests are processed within 72 hours from receipt. After approval, override and notifications are sent to the physician and member.\"},{\"question\":\"What deadlines and timelines apply to appeal requests?\",\"answer\":\"Appeal requests must be received within 180 days of the adverse determination letter. Urgent pre-service appeals are completed within 72 hours; non-urgent pre-service appeals use plan-specific two-level timelines of 15 days per level, and post-service appeals are completed within 30 days. Second-level appeals also must be received within 180 days for review and potential external review.\"}]","CVS Caremark Prior Authorizations and Appeals Program - Prior Authorization (PA) Program - Appeals Program | PDF",1789632959]