[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-288469-105":53,"doc-detail-288469-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","prior-authorization-form-hyperinflationnon-covered-drugs-medical-necessity","Prior Authorization Form - Hyperinflation/Non-Covered Drugs Medical Necessity","","Prior Authorization Form for Hyperinflation/Non-Covered Drugs Medical Necessity to support medical coverage decisions. Collects drug, patient, diagnosis, and prescribing physician details, and includes check-based questions verifying whether the requested drug use is FDA-approved or supported by current literature, whether dosing matches approved labeling or guidelines, and whether formulary alternatives were tried or are contraindicated. Requires provider attestation of medical necessity, accuracy of information, and availability of supporting documentation upon request, with signed forms faxed to CVS/Caremark.",{"@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/prior-authorization-form-hyperinflationnon-covered-drugs-medical-necessity/288469/",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/prior-authorization-form-hyperinflationnon-covered-drugs-medical-necessity/288469.png","ImageObject",442,249,{"name":88,"@type":89},"Putri","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-23","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},"Where should the signed prior authorization form be sent, and who should be contacted for questions?","Question",{"text":108,"@type":109},"Fax the signed form to CVS/Caremark at 1-888-836-0730. 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Complete/review information, sign and date. Fax signed forms to CVS/Caremark at 1-888-836-0730. 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 Hyperinflation Non-Covered Drugs Medical Necessity. |\n\n\n| DRUG INFORMATION |  |  |  |\n| --- | --- | --- | --- |\n| Drug Name (specify drug) |  |  | Quantity |\n| Frequency | Strength | Route of Administration | Expected Length of Therapy |\n\n\n| PATIENT INFORMATION |  |  |  |\n| --- | --- | --- | --- |\n| Patient Name |  |  |  |\n| Patient ID | Patient Group No. | Patient DOB | Patient Phone |\n\n\n| PRESCRIBING PHYSICIAN |  |  |\n| --- | --- | --- |\n| Physician Name | Physician Phone | Physician Fax |\n| Physician Address |  |  |\n| City | State | Zip |\n\n\n| ADDITIONAL INFORMATION |  |  |\n| --- | --- | --- |\n| Diagnosis | ICD Code |  |\n| Comments |  |  |\n| Please check the appropriate answer for each question. |  |  |\n| 1. The patient’s drug benefit plan provides coverage for other drugs which may be considered for treating your patient. Can your patient’s treatment be switched to a formulary drug? (If yes, provide your patient with a new prescription for the formulary product.) Available Formulary Alternatives: See Preferred Drug List. |  | Yes No |\n| 2. Is the requested drug being used for an FDA-approved indication OR an indication supported in the compendia of current literature (examples: AHFS, Micromedex, current accepted guidelines)? |  | Yes No |\n| 3. Does the prescribed dose and quantity fall within the FDA approved labeling or within dosing guidelines found in the compendia of current literature? |  | Yes No |\n| 4. Has the patient tried and had an inadequate treatment response or intolerance to the required number of formulary alternatives. If yes, then documentation is required for approval (Drug Name and Reason for Failure) .\u003Cbr>Note: Formulary alternatives should be prescribed first unless the patient is unable to use or receive treatment with the\u003Cbr>alternative. Required Formulary Alternatives: See Preferred Drug List (If yes, no further questions.) |  | Yes No |\n| Does the patient have a contraindication to all the alternatives? |  | Yes No |\n\n\n| SIGNATURE |\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| Prescriber (or Authorized) Signature and Date |\n\nCareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., CareFirst BlueChoice, Inc., The Dental Network and First Care, Inc. are independent licensees of the Blue Cross and Blue Shield Association. In the District of Columbia and Maryland, CareFirst MedPlus is the business name of First Care, Inc. In Virginia, CareFirst MedPlus is the business name of First Care, Inc. of Maryland (used in VA by: First Care, Inc.) . The Blue Cross® and Blue Shield® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.  \n1 SUM5320-1E (5/20)","cbCait6q2gX4AwSk","https://ap.wps.com/l/cbCait6q2gX4AwSk","pdf",90207,"English","# Instructions\n# Drug Information\n# Patient Information\n# Prescribing Physician\n# Additional Information\n# Signature","[{\"question\":\"Where should the signed prior authorization form be sent, and who should be contacted for questions?\",\"answer\":\"Fax the signed form to CVS/Caremark at 1-888-836-0730. Contact CVS/Caremark at 1-800-294-5979 for questions about the prior authorization process.\"},{\"question\":\"What information is required about the requested drug?\",\"answer\":\"Provide the drug name, quantity, frequency, strength, route of administration, and expected length of therapy.\"},{\"question\":\"What must the prescriber attest to on the signature section?\",\"answer\":\"The prescriber (or authorized signer) attests the medication is medically necessary, the submitted information is accurate and true, and supporting documentation is available for review if requested.\"}]","Prior Authorization Form - Hyperinflation/Non-Covered Drugs Medical Necessity | PDF"]