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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:

The first time ALWAYS send requested clinical documentation.

  • 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 MDH clinical criteria.
  • Please consider formulary alternatives first.

PDMP Update

  • 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.

Quick References

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:

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, access the Maryland Department of Health (MDH) website.

A pharmacist may dispense an emergency supply of the medications for formulary medication that requires a prior authorization (PA) or non-formulary medication, according to the Guidelines for Emergency Fills.  For additional assistance call CVS Health’s Pharmacy Help Desk at 1-800-345-5413.

  • All Direct-Acting Antivirals (DAA) require Prior Authorization.
  • Preferred products include generic Epclusa and Mavyret.
  • Find current MDH clinical criteria.
  • Sustained Virologic Response (SVR) should be obtained 12 weeks after therapy completion.

You can get Hepatitis C medicines through CareFirst CHPMD's preferred specialty pharmacy network, including CVS Specialty Pharmacy and select University of Maryland Specialty Pharmacies. You may also be able to fill your prescription at a pharmacy near you if it can provide the medicine and education to use it safely and correctly. In some cases, an override may be required before a Hepatitis C medicine can be covered at a retail pharmacy. If a pharmacy is not in the CareFirst CHPMD network, your prescription may not be covered. If this happens, you or your provider can contact CVS Caremark for help and learn about your options.