Prescription Claim Form (138 KB PDF) If your medication requires Prior Authorization, you may print the appropriate form and take it to your doctor to submit.	Enlarge Text
Medicare Part D 2010 Prior Authorization Criteria (66 KB PDF) Medicare Part D 2010 Prior Authorization Request Forms (for providers)
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 Medicare Part D Coverage Determination Request Form (for providers) Medicare Redetermination Request Form (31 KB PDF) If you would like to designate someone to speak on your behalf, please print and complete the appropriate form and mail to Medi-Pak Rx (PDP) Privacy Office, P.O. Box 3835, Scranton, PA 18505. If you have questions regarding the designation process, please call 1-877-233-7022. Can I Appoint a Representative? Designate someone to ask questions on my behalf (6 KB PDF)

H4213_Advantage_REV Website Submission (12/03/09)