How to Fax a Prior Authorization to a Pharmacy Plan

A prescription gets rejected at the counter, the pharmacist says "it needs a prior authorization," and the paperwork lands on a prescriber, a medical assistant, or the patient trying to move it along. Pharmacy benefit managers still run prior authorization largely by fax: the plan publishes a PA form, the prescriber fills it in, signs the medical-necessity attestation and faxes it with any supporting records, and the determination comes back the same way. Electronic PA portals exist and many practices use them, and some plans now ask for electronic submission only: CVS Caremark's current commercial PA form prints no fax number and says to submit requests electronically via ePA. This guide covers who can submit, where the real fax number is, what Caremark's own pages show, what to attach, and how to prove the request went in.

Send a fax now, $1.00

Who Submits It

The prescriber, or the prescriber's office. Every plan's PA form carries a prescriber signature line and an attestation such as "I attest that the medication requested is medically necessary for this patient." A patient cannot sign that line. Under Medicare Part D, though, the patient or the patient's representative can also ask the plan for a coverage determination directly, and plans covering essential health benefits let the patient request a formulary exception; for an exception, the prescriber still has to supply a statement of the medical reason. Beyond that, what a patient can do is fax supporting documents the plan or the prescriber asks for, fax an appeal of a denial, and fax a completed form to the prescriber's office so it can be signed and sent on. For a solo practice or a small clinic with no PA portal subscription, a one-dollar fax of the signed form is the whole workflow.

Other large pharmacy benefit managers and health plans publish their own PA forms with their own fax numbers, and those numbers often differ by line of business: commercial, Medicare Part D and Medicaid plans at the same company can route to different fax lines. We do not list numbers we could not confirm from the plan's own published form. The reliable sources are the form itself, the plan's provider page, and the rejection message the pharmacy received, which often names the plan and the PA line.

Send a fax now, $1.00

What to Attach

The completed, signed PA form on top. Then only what the plan's criteria ask for: the diagnosis and relevant codes, the drugs already tried and why they failed or were not tolerated, recent lab values where the criteria name them, and a short letter of medical necessity if the drug is off-formulary or the case is unusual. Chart notes are useful only where they show the specific thing the criteria require; a 30-page chart dump slows a reviewer down. Our medical documents guide and medical records guide cover HIPAA cover sheets and scanning records so they stay legible.

What to Put on Every Page

The patient's name and date of birth, the member ID from the insurance card, the drug name and strength, the prescriber's name and NPI, and the date, on every page. The cover page should also say "Prior authorization request" or "Appeal of PA denial," the plan name, and the number of pages. If the plan has an urgent or expedited review process, mark the cover page "Expedited" and state the clinical reason in one line. Under Medicare Part D an expedited request can also be made by phone, and the plan must expedite it when the prescriber says the standard timeframe could seriously jeopardize the patient's life, health, or ability to regain maximum function.

Appeals and Denials

A denial letter states the reason, the appeal deadline and the fax number for appeals, which may be different from the PA intake number. Fax the appeal to the number on the denial letter, with the denial letter as the first attachment after your cover page, then the new evidence that answers the stated reason. Patients can file appeals themselves. Our patient assistance guide covers the manufacturer route when a drug stays denied.

Send a fax now, $1.00

Proof the Request Went In

Your confirmation email records the destination number, the page count and the exact time the plan's machine accepted the fax. When the pharmacy says "we have nothing on file" three days later, that email, with a copy of the form, is what gets the plan to find it. Keep it with the chart or the patient's file. Under federal rules, Medicare Part D plans must decide a standard request within 72 hours and an expedited one within 24 hours, and plans covering essential health benefits have the same 72 and 24 hour limits for exception requests, while other plans set their own timelines on their form or letter; if nothing has come back by then, call the plan's PA line with the fax time in hand.

Frequently Asked Questions