*May not result in near real-time decisions for all prior authorization types and reasons.
structured to meet applicable standards for National Committee for Quality Assurance (NCQA), American Accreditation HealthCare Commission (URAC), state or Federal agencies. updated yearly and when the drug indication or safety information changes. externally reviewed by credentialed practitioners. internally reviewed by one CVS Caremark physician. based on the latest FDA-approved product labeling, uses listed in authorized compendia supported by an adequate level of clinical evidence, national guidelines and peer-reviewed literature published in scientific journals where the drug is recommended as safe and effective. 
Prior Authorization tools are comprised of objective criteria that are based on sound clinical evidence.
Post Limit Prior Authorization – A defined set of criteria under which a specific quantity may be covered when a Drug Limitation has been exceeded. Post Step Therapy Prior Authorization – A defined set of criteria under which a specific quantity may be covered when the Step Therapy requirements have not been met. Prior Authorization – A defined set of criteria under which a drug may be covered under a pharmacy benefit. 
Prior Authorization tools are comprised of several different components including:
used for condition that are not included in the pharmacy benefit, such as cosmetic uses. subject to overuse, misuse or off-label use. Prior Authorization Products, Tools and Criteriaĭrugs suitable for PA include those products that are commonly: When a PA is needed for a prescription, the member will be asked to have the physician or authorized agent of the physician contact our Prior Authorization Department to answer criteria questions to determine coverage. Prior Authorization can ensure proper patient selection, dosage, drug administration and duration of selected drugs. CVS Caremark Prior Authorization (PA) tools are developed to ensure safe, effective and appropriate use of selected drugs.
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