Pharmacy Authorizations and Medication Exceptions
Please contact CVS Caremark for PA (Prior Authorization), QL (Quantity Limit), ST (Step Therapy), or Medication Exception review. You may:
- Call CVS/Caremark CareFirst CHPMD PA line at 1-877-418-4133. Hours are Monday-Friday 9:00 a.m. to 7:00 p.m., Saturday-Sunday 8:00 a.m. to 5:30 p.m., closed Holidays. Please be prepared to provide the clinical reviewer supporting documentation during this call. Or when you call CVS choose Option 1 to obtain a CVS Clinical Prior Authorization Criteria Request Form. This form can be used to begin the medication exception process. Or, you may CLICK HERE to download a Clinical Prior Authorization Criteria Request Form to request medication specific clinical criteria.
- Fax the completed Formulary Exception/Prior Authorization Request Form with clinical information to CVS Caremark at 1-855-762-5205. CLICK HERE to download the Formulary Exception/Prior Authorization Request Form
- Submit an electronic PA request to CVS Caremark through CoverMyMeds, CLICK HERE.
Tips on Getting Your Medically Necessary Pharmacy Prior Authorization Approved
- Respond to CVS/Caremark inquiry within 24 hours to avoid unnecessary denials and delay in treatment. CVS Prior Authorization 1-877-418-4133
- Step-therapy/Non-Formulary – Provide documentation of treatment failure with Formulary alternatives
- Member new to Provider or Plan – Provide documentation and length of prior treatment success with requested drug
- Hepatitis C medications – See Hepatitis C section or check current criteria on DHMH website at https://mmcp.dhmh.maryland.gov/pap/Pages/Hepatitis-C-Therapy.aspx
- Opioid Analgesics – Not effective until 3/1/2017–See Opioid section
Please consider formulary alternatives first.
- Click here for more information at Chesapeake Regional Information System for our Patients (CRISP)
- Effective July 1, 2017, Practitioners authorized to prescribe CDS in Maryland must be registered with the PDMP
- Beginning July 1, 2018, Prescribers must, with some exceptions, query and review their patient’s PDMP data prior to initially prescribing an opioid or benzodiazepine AND at least every 90 days thereafter as long as the course of treatment continues to include prescribing an opioid or benzodiazepine. Prescribers must also document PDMP data query and review in the patient’s medical record.
- Guideline for Opioids for Chronic Pain (CDC)
- MME-Calculating Opioid Total Daily Dose (CDC)
- Tapering Opioids for Chronic Pain (CDC)
- Selected Important Safety Information for ER/LA Opiates (FDA)
- Preventing Fatal Opioid Overdose (Prescribe to Prevent)
- The new CDC Opioid Guideline App is now available for free download for smartphones (iOS and Android).
Maryland Medicaid has implemented policy changes recommended by the Centers for Disease Control and Prevention for both Medicaid fee-for-service and all HealthChoice Managed Care Organizations (MCOs) that will:
- Prevent medical and non-medical opioid misuse, abuse, and addiction from developing;
- Identify and treat opioid dependence early in the course of the disease;
- Prevent overdose deaths, medical complications, psychosocial deterioration, transition to injection drug use, and injection-related disease; and
- Use data to monitor and evaluate activities.
Effective July 1, 2017, CareFirst Community Health Plan Maryland (CareFirst CHPMD) requires a PRIOR AUTHORIZATION (PA) for 6 months, unless indicated otherwise, for certain opioid prescriptions as described below:
- Long-acting or Extended-release opioids, fentanyl, and methadone for moderate-to-severe pain
- Opioid therapy exceeding 90 MME (morphine milligram equivalent) daily
- Opioid prescription resulting in a member’s cumulative morphine milligram equivalent exceeding 90 MME
- Immediate-release (IR) opioid prescriptions for a duration of greater than thirty (30) days for chronic pain and greater than seven (7) days for acute pain (PA for 1 month)
Note: A lifetime PA will be provided for members with sickle cell anemia and members in a Hospice setting. Members with active cancer or in a Long-Term Care facility will be approved for six months.
- In addition to meeting clinical criteria for medical necessity, the PA will require prescriber to:
- Review patient’s Controlled Substances Prescriptions in PDMP (CRISP).
- Monitor patient with random drug screen(s) before and during treatment.
- Provide or offer naloxone prescription to patient/patient’s household.
- Attest there is a Patient-Prescriber Pain Management/Opioid Treatment Agreement/Contract
- Ensure there is medical justification for high-dose and/or long-acting opioid prescription;
- Verify member’s clinical situation to determine medical necessity
All CareFirst CHPMD PAs are handled by CVS Caremark. PA decisions are made within 24 hours upon receipt of all clinical information. Providers may request a PA by any one of the following:
- Complete the CareFirst CHPMD Analgesic Opioid PA form or the MD Medicaid/MCO Universal Opioid PA form and fax it to CVS/Caremark at 1-855-762-5205
- Call CVS/Caremark CareFirst CHPMD PA line at 1-877-418-4133. Hours are Monday-Friday 9:00 a.m. to 7:00 p.m., Saturday-Sunday 8:00 a.m. to 5:30 p.m., closed Holidays.
- Go to https://www.covermymeds.com/epa/caremark/ to submit an electronic PA request to CVS through CoverMyMeds
Before prescribing an opioid or any controlled substance, providers should use standardized tool(s) to screen for substance use. Click here to see resources for the Maryland Screening, Brief Intervention, Referral to Treatment (SBIRT).
Click here to refer patients identified as having Substance Use Disorder to Optum.
For additional information, you can access the Maryland Department of Health (MDH) website by clicking here.
Questions & Answers
Q: Are opioid prescriptions for patients discharged from the hospital or an acute care setting subject to a PA?
Q: If I write an opioid prescription under the 90 MME/day and for a 30-day supply, is a PA required?
A: In general, no. However, if a patient had filled another opioid prescription and received an approved PA within the last 6 months, there is a potential your opioid prescription will require a PA if it results in the members cumulative MME to exceed 90mg
Q: What recourse do I have when a PA is not approved and I believe a patient still requires a high dose opioid prescription?
A: You or your patient have the right to appeal to the CareFirst CHPMD. Details of the process will be included in the denial letter.
Q: When can I submit a Prior Authorization?
A: Beginning 7/1/2017, providers may fax and electronically submit PA requests at any time. The Caremark CareFirst CHPMD PA Department call hours are Monday-Friday 9:00 a.m. to 7:00 p.m., Saturday-Sunday 8:00 a.m. to 5:30 p.m., closed Holidays. CVS Caremark Customer Service is available 24/7.
Mental Health/Pharmacy Authorizations
HIV Pharmacy Authorizations
- Effective 01/01/2020, HIV medications will no longer be processed by CareFirst Community Health Plan Maryland (CareFirst CHPMD).
- HIV medications will now be covered under the pharmacy benefit for CareFirst CHPMD.
- CareFirst Community Health Plan Maryland will require a copay of $0 for generic medications and $3 for brand medications.
- A six-month grace period will be implemented to allow a continuation of current treatment regimens (01/01/2020-06/30/2020).
- Formulary restrictions will be implemented on 07/01/2020. Members 21 years of age or younger will not be subject to formulary restrictions in the antiretroviral class.
Hepatitis C Therapy
- •All Direct-Acting Antivirals (DAA) require Prior Authorization: Epclusa, Harvoni, Mavyret, Vosevi, Zepatier•Click here to find current MDH Clinical Criteria, measures of liver fibrosis, Treatment Plan, DHMH PA form, and viral load clarification.•Liver fibrosis must be equivalent to a Metavir score F0•Provider must assess and provide attestation to member’s adherence;•Viral Load (VL) must be obtained: •between weeks 2-6 for 12-week therapy and between weeks 8-14 for 24-week therapy•Within 30 days after End of Therapy (EOT)