Arkansas BlueCross Blue Shield Medi-Pak Choice
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2010 Medi-Pak Rx (PDP) Forms


If your medication requires Prior Authorization, you may print the appropriate form and take it to your doctor to submit.


To request a coverage determination or redetermination, please print and complete the appropriate form and fax it to CVS Caremark Appeals at 1-866-884-9475 or mail it to CVS Caremark Appeals at PO Box 52000, Phoenix, AZ, 85072-2000. If you have questions regarding the prior authorization process, please call 1-866-494-5829.




S5795_Rx_REV Website Submission (12/07/09)

Web Page Last Updated: 12/15/2010