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) form.
Medicare Part D Medications That Require Prior Authorization
Arkansas Blue Cross and Blue Shield is an Independent Licensee of the Blue Cross
and Blue Shield Association and is licensed to offer health plans in all 75 counties
of Arkansas. Copyright © 2001-2015 Arkansas Blue Cross and Blue Shield