Prescription Claim Form (PDF) If your medication requires Prior Authorization, you may print the appropriate form and take it to your doctor to submit.

Medicare Part D 2011 Prior Authorization Criteria Medicare Part D Prior Authorization Request Forms

To request a coverage determination or redetermination, please print and complete the appropriate form and fax 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 1-866-494-6699.

Medicare Prescription Drug Determination Request Form (pdf) Medicare Part D Coverage Determination Request Form (for providers) (pdf) Medicare Redetermination Request Form (PDF)

H4213_Advantage_REV Website Submission (12/03/09)

Web Page Last Updated: 8/30/2011