"Formulary exception" sounds like it needs its own special paperwork, separate from ordinary prior authorization. It doesn't. CVS Caremark runs both processes through the same Formulary Exception/Prior Authorization Request Form, and the confusion over that fact is probably the single biggest reason people delay filing one.
A formulary exception is really just a specific type of prior authorization request: instead of asking permission to use a drug that requires PA by design, you're asking Caremark to cover something that isn't on the formulary at all, or to waive a quantity limit or step therapy requirement standing in the way of it. The mechanism — one form, filled out by your prescriber, reviewed against clinical criteria — is identical either way.
This guide walks through exactly what that form asks for, how to submit it correctly the first time, what timelines apply once it's in, and what to do if it comes back denied.
Table of Contents
- What a Formulary Exception Actually Is
- The Three Request Types on One Form
- What the Form Actually Asks For
- How to Submit: ePA, Fax, or Phone
- Review Timelines
- A Real Example, Start to Finish
- Decision Tree: Which Box Do You Check?
- Step-by-Step: Filing Without Delays
- If You're Denied: Appeals and External Review
- Common Mistakes That Cause Denials
- Frequently Asked Questions
What a Formulary Exception Actually Is
Every health plan's pharmacy benefit is built around a formulary — a list of covered drugs, organized into tiers, with rules attached to some of them. A formulary exception is a request to step outside that list or those rules for a specific patient, based on medical necessity.
| Situation | Is It a Formulary Exception? |
|---|---|
| Drug isn't on the formulary at all | Yes — non-formulary exception |
| Drug is covered but limited to a certain quantity per month | Yes — quantity limit exception |
| Drug requires trying a cheaper alternative first | Yes — step therapy exception |
| Drug is covered on formulary, no restrictions, but at a high copay tier | Sometimes — tiering exception, requesting a lower cost-sharing tier |
| Drug simply requires standard prior authorization for safety reasons | No — this is ordinary PA, though the same form is used |
The Three Request Types on One Form
CVS Caremark's Formulary Exception/Prior Authorization Request Form is built to handle several distinct scenarios without needing a different document for each one.
| Request Type | What You're Asking For | Key Documentation Needed |
|---|---|---|
| Non-formulary exception | Coverage for a drug not on the plan's formulary at all | Explanation of why formulary alternatives aren't appropriate or effective |
| Quantity limit exception | A higher quantity than the plan's standard limit allows | Clinical rationale for the higher dose or quantity |
| Step therapy exception | Skipping or bypassing a required "try this first" drug | History of failure, intolerance, or contraindication to the required step drug |
| Tiering exception | A lower copay tier for a drug that's covered but expensive | Evidence that lower-tier alternatives are ineffective or not tolerated |
You can request more than one type at once. If a drug is both non-formulary and would need a quantity above the standard limit, your prescriber can document both issues on the same submission rather than filing twice.
What the Form Actually Asks For
CVS Caremark's own guidance is direct about this: providing only demographic and drug information isn't a sufficient request. The clinical documentation is what actually gets reviewed.
| Section | What Goes Here |
|---|---|
| Patient information | Name, date of birth, member ID, plan information |
| Prescriber information | Name, NPI, contact details, office fax number for the response |
| Medication requested | Drug name, strength, dosage form, quantity, and days' supply |
| Diagnosis | ICD-10 code and clinical description supporting medical necessity |
| Clinical documentation | Prior treatments tried, outcomes, contraindications, relevant lab or visit notes |
| Expedited review checkbox | Checked only when standard timing would seriously jeopardize the patient's life, health, or ability to regain maximum function |
| Prescriber signature and date | Certification that the requested medication is medically necessary |
Certain drug classes have their own extra questions built into the form — CVS Caremark's global PA form includes specific criteria sections for categories like anti-obesity medications, continuous glucose monitors, insulin pumps, triptans, and testosterone products, among others. If your medication falls into one of these categories, expect additional clinical questions beyond the general sections.
How to Submit: ePA, Fax, or Phone
CVS Caremark accepts prior authorization and exception requests through more than one channel, and which one your prescriber's office uses often comes down to what their EHR or practice management system supports.
| Method | How It Works | Best For |
|---|---|---|
| Electronic Prior Authorization (ePA) | Submitted directly through the prescriber's EHR or a connected ePA platform | Fastest turnaround, fewer transcription errors |
| Fax | Completed form faxed to CVS Caremark's prior authorization department | Practices without ePA integration |
| Phone | Prescriber or authorized agent calls Caremark's Prior Authorization Department to answer criteria questions directly | Simple, straightforward cases with limited documentation needs |
Fax numbers and phone lines vary by plan. CVS Caremark administers pharmacy benefits for many different employer and health plans, each of which can have its own dedicated fax number or phone line. Always use the number printed on your specific insurance ID card, member portal, or the request form your prescriber's office actually has on file — a number found through a generic web search may route to the wrong plan's queue and cause delays.
Review Timelines
Timelines differ by plan type, but Medicare Part D plans — which CVS Caremark administers for many insurers — follow specific timeframes required by CMS.
| Plan Type | Standard Review | Expedited/Urgent Review |
|---|---|---|
| Medicare Part D | Generally within 72 hours | Generally within 24 hours |
| Commercial/employer plans | Varies by plan; often a similar standard/urgent structure applies under federal claims procedure rules | Typically faster, reserved for cases where delay could seriously harm the patient |
| Medicaid managed care | Varies by state; often subject to state-specific timeframes | Varies by state; expedited pathways generally required for urgent cases |
The clock generally starts when Caremark has a complete request. A submission missing required clinical documentation may be returned or delayed before the formal review timeline even begins, which is why documentation completeness matters as much as speed of submission.
A Real Example, Start to Finish
Here's how a step therapy exception request might play out for a patient prescribed a brand-name migraine medication after a plan's preferred triptan didn't work.
Pharmacy rejects the claim
The pharmacist sees a step-therapy rejection code at the register and tells the patient a prior authorization or exception request is needed.
Patient calls the prescriber's office
The office pulls the CVS Caremark Formulary Exception/Prior Authorization Request Form, or accesses the equivalent request through their ePA system.
Prescriber documents the step therapy failure
The form's step therapy section is completed with the name of the previously tried triptan, the outcome (inadequate relief, or a specific adverse reaction), and the dates it was used.
Submission goes in via ePA
The request is submitted electronically, with the office's fax number included as a backup contact for Caremark's response.
Decision arrives within the standard window
Because this wasn't marked urgent, Caremark's decision comes back within the standard review timeframe rather than the expedited one — approved, based on the documented step therapy failure.
Decision Tree: Which Box Do You Check?
Why was the claim rejected at the pharmacy?
The rejection reason determines which exception type applies
Check non-formulary or quantity limit exception
Document why alternatives won't work or higher quantity is needed
Check step therapy exception
Document prior failure, intolerance, or contraindication
Could waiting seriously harm the patient?
If yes, check the expedited/urgent review box
Submit via ePA, fax, or phone
Use the number/portal tied to the specific plan, not a generic search result
Step-by-Step: Filing Without Delays
Confirm the exact rejection reason first
Ask the pharmacist for the specific rejection code or reason, not just "it needs prior authorization." Non-formulary, quantity limit, and step therapy rejections each call for slightly different documentation.
Get the correct plan-specific submission method
Check the insurance ID card or member portal for the fax number or ePA pathway tied to your specific plan rather than a generic number found online.
Bring your medication history to the appointment
If this is a step therapy exception, having dates and outcomes of previously tried medications ready speeds up the documentation your prescriber needs to write.
Ask your prescriber's office who handles PA paperwork
Many practices have a specific staff member or nurse dedicated to prior authorization and exception requests — asking for that person by role can get your request into the right hands faster.
Confirm whether urgent review applies
If delaying the medication could seriously jeopardize your health, tell your prescriber's office directly so they can evaluate whether to check the expedited review box.
Follow up if you haven't heard back
If the standard or expedited window has passed without a decision, call the number on your ID card to check status rather than assuming denial or waiting indefinitely.
If You're Denied: Appeals and External Review
A denial on a formulary exception request is not the end of the process. Most plans build in at least one internal appeal step and, if that fails, an independent external review.
| Stage | What Happens |
|---|---|
| Initial denial | You receive a written explanation of the specific reason for denial |
| Internal appeal (redetermination for Part D) | Your prescriber submits additional documentation addressing the stated denial reason |
| Independent external review | A reviewer outside the plan evaluates the case, generally available if the internal appeal is also denied |
Read the denial letter closely before appealing. It should state the specific clinical criterion that wasn't met. An appeal that directly addresses that stated reason — rather than simply resubmitting the same information — has a meaningfully better chance of success.
Common Mistakes That Cause Denials
| Mistake | Why It Causes Problems |
|---|---|
| Only demographic and drug information submitted | Caremark's own guidance states this alone isn't a sufficient request |
| Missing ICD-10 diagnosis code | Reviewers can't evaluate medical necessity without a documented diagnosis |
| No documentation of prior treatment attempts | Step therapy and tiering exceptions specifically require this history |
| Expedited box checked without justification | Can result in the request being reviewed under standard timing anyway if criteria aren't met |
| Using a fax number for the wrong plan | Can misroute the request or cause it to go unprocessed |
| Missing prescriber signature or date | Treated as an incomplete submission |
Frequently Asked Questions
CVS Caremark uses a single combined Formulary Exception/Prior Authorization Request Form for non-formulary drug requests, quantity limit exceptions, and step therapy exceptions. Your prescriber's office completes and submits it.
For Medicare Part D plans, CVS Caremark must generally decide standard exception requests within 72 hours and expedited requests within 24 hours, per CMS rules. Commercial plan timelines vary but often follow a similar standard/urgent structure.
Members can request an exception, but CVS Caremark requires a supporting statement from the prescriber explaining medical necessity, so your prescriber's office is almost always involved in the actual submission.
You can file an appeal, often called a redetermination for Medicare Part D plans. If that's denied too, further independent external review levels are generally available, depending on your plan type.
Check the expedited or urgent review box on the Formulary Exception/Prior Authorization Request Form, which requires the prescriber to certify that waiting for the standard timeframe could seriously jeopardize the patient's life, health, or ability to regain maximum function.
Not quite. A formulary exception typically asks for coverage of a drug not on the formulary at all, while a tiering exception asks for a lower copay tier on a drug that's already covered. Both use similar documentation and often the same overall form.
Fax numbers vary by the specific health plan CVS Caremark administers for your coverage. Use the number on your insurance ID card, member portal, or the plan-specific form your prescriber's office has on file rather than a number found through a general web search.
The clinical documentation and certification generally must come from the prescriber, though pharmacists commonly identify the need for the request and direct patients back to their prescriber's office to initiate it.
ePA submissions generally move faster in practice because they reduce manual data entry and transcription errors, though the formal decision timeframe itself is governed by the same standard or expedited rules regardless of submission method.
CVS Caremark's global prior authorization form includes additional category-specific clinical questions for certain drug classes, including anti-obesity medications, testosterone products, and continuous glucose monitors, among others. Expect extra documentation requirements for these categories.
How We Researched This Guide
References
- CVS Caremark — Prior Authorization program overview
- CVS Caremark — Prior Authorization and Exception Forms directory
- CVS Caremark — Global Formulary Exception/Prior Authorization Request Form (PDF)
- CMS — Medicare Part D Appeals and Exception Timeframes
Related Resources
- Ozempic Prior Authorization Requirements
- How to Appeal a Prescription Denial
- What Is a Copay Accumulator?
- Patient Assistance Program Income Limits: 2026 Comparison
- Eli Lilly Patient Assistance Program
Editorial Policy: Refill Relay medical content is researched using pharmacy benefit manager program pages and CMS guidance. Because fax numbers, submission portals, and specific plan procedures vary and can change, always confirm the current details for your specific plan directly with CVS Caremark or the number on your insurance ID card before submitting a request.