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It requires the collection of essential patient and prescribing physician details, including drug specifications, patient identification, and clinical contact information. The form includes a medical necessity verification section to be completed by the healthcare provider, ensuring compliance with health plan sponsor requirements and regulatory standards for medical necessity documentation.",{"@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":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/preventive-services-contraceptive-zero-copay-exception-prior-authorization-form/286830/",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/preventive-services-contraceptive-zero-copay-exception-prior-authorization-form/286830.png","ImageObject",442,249,{"name":88,"@type":89},"Jacob","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-27","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":47},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"How should the completed form be submitted?","Question",{"text":108,"@type":109},"The signed form must be faxed to CVS Caremark at 1-888-487-9257.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What is the purpose of this form?",{"text":113,"@type":109},"This form is used to request authorization for coverage of Preventive Services Contraceptive Zero Copay exceptions when specific medical conditions are met.",{"name":115,"@type":106,"acceptedAnswer":116},"Who is authorized to sign the medical necessity attestation?",{"text":117,"@type":109},"The form must be signed and dated by the prescribing physician or an authorized representative.","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},286830,1790089444,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":47,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"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":4},962084931830,"https://ap-avatar.wpscdn.com/davatar_a8503ba1806abce46bf441b54a3ca4cd","| \u003Cbr>Prior Authorization Form |\n| --- |\n|  |\n\nPreventive Services Contraceptive Zero Copay Exception* This fax machine is located in a secure location as required by HIPAA regulations.  \nComplete/review information, sign and date. Fax signed forms to CVS Caremark® at 1-888-487-9257. Please contact CVS Caremark at 1-800-294-5979 with questions regarding the prior authorization process. When conditions are met, we will authorize the coverage of Preventive Services Contraceptive Zero Copay  \nException* .  \nDrug Name  \nQuantity Frequency Strength  \nRoute of Administration Expected Length of Therapy  \nPatient Information  \nPatient Name:    \nPatient ID:    \nPatient Group No.:    \nPatient DOB:    \nPatient Phone:  \nPrescribing Physician  \nPhysician Name:   Physician Phone:    \nPhysician Fax:    \nPhysician Address:   City, State, Zip:    \nComments:    \nPlease circle the appropriate answer for each question.  \n\n| 1. Has the attending health care provider determined the requested  Y N  drug to be medically necessary for the patient as a preventive service? |  |\n| --- | --- |\n\n\n| I attest that the medication requested is medically necessary for this patient. I further attest that the information provided is accurate and true, and that the documentation supporting this information is available for review if requested by the claims processor, the health plan sponsor, or, if applicable a state or federal regulatory agency. |\n| --- |\n| Prescriber (Or Authorized) Signature and Date |\n\n106-1144597A 030325","cbCaikLUSIU8fqKl","https://ap.wps.com/l/cbCaikLUSIU8fqKl","pdf",89361,"English","# Patient and Drug Information\n## Prescribing Physician Details\n## Medical Necessity and Attestation","[{\"question\":\"How should the completed form be submitted?\",\"answer\":\"The signed form must be faxed to CVS Caremark at 1-888-487-9257.\"},{\"question\":\"What is the purpose of this form?\",\"answer\":\"This form is used to request authorization for coverage of Preventive Services Contraceptive Zero Copay exceptions when specific medical conditions are met.\"},{\"question\":\"Who is authorized to sign the medical necessity attestation?\",\"answer\":\"The form must be signed and dated by the prescribing physician or an authorized representative.\"}]","Preventive Services Contraceptive Zero Copay Exception - Prior Authorization Form | PDF",1789631596]