CVS Caremark Prior Authorization Request Form

The CVS Caremark (formerly Rx America) Prior Authorization Request Form is used when the provider requests special consideration on behalf of an AHCCCS Fee-For-Service (FFS) recipient for a non-covered medication, as indicated by the AHCCCS FFS Formulary. This form applies to AHCCCS FFS recipients only and is not valid for recipients enrolled in any of the AHCCCS Managed Care Plans.

CVS Caremark Prior Authorization Request Form [PDF, 71KB]

Contact

After faxing the Prior Authorization request form above, you may contact CVS Caremark directly at 1-866-546-0663 to follow up. Prior authorizations can not be performed over the phone. All requests must be faxed.

Please allow at least 24 hours for your request to be processed. Incomplete requests may delay this process.