Listed on caremark.com as the Global Prior Authorization Form, this two-page request is what prescribers use when a commercial (non-Medicare) CVS Caremark plan requires prior authorization or a formulary exception for a drug. It also serves quantity-limit, step-therapy and non-formulary exception reviews. Reviewers weigh the answers and attached chart notes against the plan's criteria, and the plan may ask for more information before deciding.
The prescriber completes the whole form, from patient and prescriber details through the clinical questions and any drug-class section that applies, and signs the attestation. It also names a contact person at the doctor's office for the plan's follow-up questions.
Enter the patient's name, date of birth, patient ID number, address, home phone and gender. On the prescriber side, give the prescriber's name, NPI, address, office phone, a secure office fax number and a contact person at the doctor's office. The form states that the prescription benefit plan may request additional information or clarification, so the fax and contact person should reach someone in the office who can answer clinical questions about the request.
List the medication and strength, directions for use with frequency, expected length of therapy, quantity, day supply, ICD-10 code and diagnosis, and route of administration. The banner beneath this block says that providing only demographic and drug information may not constitute a sufficient request for coverage, and asks for all relevant clinical documentation to be attached for a thorough review. Quantity and day supply define the request when it is really a quantity-limit exception.
Check this box only when applying the standard review time frame may seriously jeopardize the patient's life or health or the patient's ability to regain maximum function. By checking it and signing the form, the prescriber certifies that this standard is met. Leave it blank for routine requests; the remaining questions are completed the same way for both review types.
Five questions establish whether the patient is already on the drug: whether it was received within the last 120 days, whether it was dispensed and approved for coverage by a prior plan, how long the patient has taken it, whether there has been a positive response or improvement in symptoms, and whether the need for continued therapy was assessed within the previous year. These answers matter most for a patient who changed plans while stable on a medication.
Answer whether the drug is used for an FDA-approved indication or one supported in the compendia of current literature (examples given are AHFS, Micromedex and current accepted guidelines), and whether the dose and quantity fall within FDA labeling or compendia dosing. Then list ALL medications the patient has tried for this diagnosis, each with an explanation for failure or contraindication. Three lines are printed, with a further line for all other medications tried and the reasons they failed.
Four questions capture common exception grounds. The first covers a patient with a highly sensitive condition, such as a psychiatric condition, epilepsy or organ transplant, who is stable on the current drug and at high risk of harm from a change; name the anticipated adverse event. The second asks for the diagnostic test and date confirming a chronic condition. The third asks for any required dosage form, such as a suspension or injection, with the clinical reason. The fourth covers comorbidities or drug interactions that rule out formulary alternatives, with medication names and reasons.
For test strips, give the make and model of any insulin pump the patient uses and state whether the pump is incompatible with Accu-Chek or OneTouch products. For a CGM, answer whether the patient is on an intensive insulin regimen, whether a continuing patient is assessed every 6 months for adherence to the CGM regimen and diabetes treatment plan, and whether the patient is not meeting glycemic targets or is experiencing hypoglycemia.
The prescriber attests that the medication is medically necessary, that the information is accurate and true, and that supporting documentation is available if CVS Caremark, the health plan sponsor or a state or federal regulatory agency requests it. The attestation cites the federal and state False Claims Acts (31 U.S.C. §§ 3729-3733) for false statements material to claims paid by government. Sign and date it; the expedited-review certification is made by checking that box and signing here.
The bottom of page 1 and all of page 2 carry question sets for topical antifungals, antiobesity drugs, CGRP receptor antagonists, erectile dysfunction drugs, Provigil and Nuvigil, stimulants, topical acne products and testosterone products. Check the box for the class requested, then circle Yes or No or supply the response. The antiobesity set requires supporting chart notes with dated weights, and the stimulant set asks how an ADHD diagnosis was documented, such as DSM-5 assessment or standardized rating scales.
Download the current version from the source each time; forms change without notice.
Formulary Exception/Prior Authorization Request Form
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Sources for this guide
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Yes. The form is titled Formulary Exception/Prior Authorization Request Form, and Caremark notes that a plan may use the term prior authorization to include exception reviews for quantity limitations. It is also used for step-therapy and non-formulary exception reviews on commercial plans. Medicare Part D exceptions go on the form posted by the patient's Part D plan.
Check the Expedited/Urgent Review Requested box below the Drug Information block and sign the form. By doing so you certify that applying the standard review time frame may seriously jeopardize the patient's life or health or the patient's ability to regain maximum function. The certification is made by checking the box and signing at the bottom of page 1.
The form warns that demographic and drug information alone may not be a sufficient request and asks for all relevant clinical documentation. Attach chart notes supporting the diagnosis, every drug tried and why it failed or was contraindicated, and any diagnostic test with its date. Antiobesity requests also need dated weights from before and after therapy.
The current posting carries the code 106-37207A 081826 in the footer of each page, reflecting an August 18, 2026 revision. Older copies, including a file named Global_Prior_Authorization_Form.pdf, still circulate. Download the form from Caremark's prior authorization page for each request rather than reusing a saved copy, so the drug-class questions match the current version.