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://health.maryland.gov/mmcp/pap/Pages/Hepatitis-C-Therapy.aspx
- Please consider formulary alternatives first.
- Click here for more information at Chesapeake Regional Information System for our Patients (CRISP)
- Practitioners authorized to prescribe CDS in Maryland must be registered with the PDMP
- 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.
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. Members in a Long-Term Care facility, hospice, palliative care, or with active cancer 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.
Hepatitis C Therapy
- All Direct-Acting Antivirals (DAA) require Prior Authorization.
- Preferred products include generic Epclusa and Mavyret.
- Click here to find current MDH Clinical Criteria.
- Sustained Virologic Response (SVR) should be obtained 12 weeks after therapy completion.
- Member must use an in-network Specialty Pharmacy. Provider should contact either CVS Specialty, Call: 1-800-237-2767, Fax: 1-800-323-2445 or select University of Maryland Medical System (UMMS) Pharmacy Services, Call: 855-547-4276, Fax: 410-684-3776