Prescriber Criteria Form - Prescriber Services 2026 PA Fax BD-13 v1 010126 - Coverage Determination

Sep 17, 2026

Prescriber Criteria Form for Prescriber Services 2026 PA Fax BD-13 v1 010126 collects prescriber and patient details to support prior authorization. The form documents whether the requested drug is supplied from practitioner and/or office stock and billed as part of a practitioner service “incident to a practitioner’s service.” It includes fields for drug and diagnosis information, contact details, comments, and a signed attestation that provided information is accurate and documentation is available for health plan review.

LanguageEnglish

CategoryForms

FormatPDF

Pages1

AccessFree to download

Coverage Determination

Submission and HIPAA attestation

Practitioner and patient information

Drug and diagnosis details

Incident to criteria question

Comments and signature

FAQs

Where should the signed faxed form be sent for prior authorization processing?

Fax the signed forms to CVS Caremark at 1-855-633-7673.

How does the form define the “incident to a practitioner’s service” requirement?

The form asks whether the requested drug is being supplied from practitioner and/or office stock and billed as part of a practitioner service, meaning the drug is furnished “incident to a practitioner’s service.”

What attestation is made by the prescriber signature on the form?

By signing, the prescriber (or authorized representative) attests that the information is accurate and true as of the date and that supporting documentation is available for health plan review if requested.

Sep 17, 2026

Upload by Ben Jamin