CareFirst Taltz Prior Authorization Request
This file is a Prior Authorization Request form for Taltz medication managed by CVS Caremark on behalf of CareFirst. It's used for various diagnoses including plaque psoriasis and psoriatic arthritis. Physicians need to fill out patient information and medication history.
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How do I fill this out?
To fill out this form, you'll need detailed patient information, medical history, and specific details about the requested medication. Answer all relevant questions accurately. Ensure all sections are completed before submitting.
How to fill out the CareFirst Taltz Prior Authorization Request?
1
Fill out patient's information including name, date of birth, and ID.
2
Provide physician's details including name, specialty, NPI#, fax, and telephone.
3
Answer diagnosis and medication-related questions accurately.
4
Document any inadequate responses or adverse events with previous treatments.
5
Sign and date the form before submitting.
Who needs the CareFirst Taltz Prior Authorization Request?
1
Physicians requesting prior authorization for Taltz medication.
2
Healthcare providers managing patients with plaque psoriasis.
3
Specialists treating patients with psoriatic arthritis.
4
Medical office personnel handling insurance and medication authorizations.
5
Pharmacists coordinating with physicians for patient medication plans.
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2
Use the PDF editor to fill in the necessary information.
3
Make sure all fields are completed accurately.
4
Add any additional notes or details as required.
5
Save the edited PDF and prepare for submission.
What are the instructions for submitting this form?
To submit this form, fax the completed document to CVS Caremark at 1-866-249-6155. For electronic submission, visit CoverMyMeds at www.covermymeds.com/epa/caremark/. If you have questions regarding the submission, contact CVS Caremark at 1-866-814-5506. Make sure to complete all required fields and include any supporting documentation. Incomplete forms may result in delays.
What are the important dates for this form in 2024 and 2025?
Key dates for the form may include authorization start and end dates, patient consultation dates, and medication dispensing dates. Ensure all relevant dates are reviewed before submission.
What is the purpose of this form?
The purpose of this form is to request prior authorization for the Taltz medication through CVS Caremark. This includes detailed information on the patient's diagnosis and medical history. By completing the form accurately, physicians can ensure patients receive the necessary medication in a timely manner.
Tell me about this form and its components and fields line-by-line.
- 1. Patient's Name: Enter the full name of the patient.
- 2. Date: Provide the current date.
- 3. Patient's Date of Birth: Enter the patient's date of birth.
- 4. Patient's ID: Provide the patient's identification number.
- 5. Physician's Name: Enter the full name of the physician.
- 6. Specialty: Specify the physician's specialty.
- 7. NPI#: Provide the physician's National Provider Identifier number.
- 8. Physician Office Fax: Enter the fax number for the physician's office.
- 9. Physician Office Telephone: Provide the telephone number for the physician's office.
- 10. Request Initiated For: Specify the reason for the request.
- 11. Diagnosis: Provide the diagnosis related to the medication request.
- 12. ICD-10 Code: Enter the relevant ICD-10 code.
- 13. Preferred Product: Indicate if the patient can be switched to a preferred product.
- 14. Continuing Therapy: Specify if the request is for continuation of therapy.
- 15. Medication History: Document any previous treatments and patient responses.
- 16. Clinical Reasons: Provide any clinical reasons to avoid certain medications.
- 17. Screening Results: Include any pre-treatment screening results.
What happens if I fail to submit this form?
Failure to submit this form can delay the patient's treatment and medication authorization.
- Treatment Delay: Patients may experience delays in receiving their medication.
- Authorization Issues: Lack of prior authorization can lead to denial of medication coverage.
How do I know when to use this form?
- 1. New Medication Request: Submit for initial authorization of Taltz.
- 2. Continuing Therapy: Use for ongoing authorization of current treatment.
- 3. Switching Medication: Required when changing to Taltz from another medication.
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