Medicare Part D Prior Authorization Request Forms

Medicare Part D prior authorization forms are used by providers when requesting coverage for drugs that require prior authorization for members of Medi-Pak RX (PDP), Medi-Pak Advantage (PFFS), and Medi-Pak Advantage (PPO). These forms are in portable document format (PDF). You may print and copy them as needed.

Please complete the form, review information, sign, and date. Fax completed forms to CVS Caremark Prior Authorizations Department at 1-855-633-7673. If you have questions regarding the process or need more information, please call 1-855-344-0930.

Click on a link below to see the full list of forms available.

If the prescribed medication is not listed below please use the Medicare Coverage Determination Request [pdf, 137 KB] form.

Medicare Part D Medications That Require Prior Authorization