Request an Exception, Coverage Determination, or Prior Authorization

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Only the ordering prescriber may complete the forms below. In order to complete our review and make an appropriate determination, please indicate all applicable information. For assistance with the forms, or to inquire about the status of a request, please call our Medicare Clinical PA Department at (800) 311-0594 Monday through Friday 8:00am - 9:00pm Eastern Time.

Completed forms may be faxed to the Medicare Clinical PA Department at (800) 373-1266, or mailed to CVS Caremark Corporation, Medicare Clinical PA Department, P.O. Box 519, Lincoln, RI, 02865.

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General Forms
B vs. D Coverage Determination
Coverage Determination Request
Exception Request
Quantity Limit Exception Request

Drug Specific Forms
Aranesp
Emend
Enbrel
Epogen
Exjade
Humira
Increlex
Infergen
Insulin Pen
Kineret
Lotronex
Lupron (Female)
Lupron (Male)
Neupogen
Octreotide
Oxandrolone
Pegasys
PEG-Intron
Penlac
Procrit
Prolastin
Provigil
Rebif
Remicade
Revatio
Somatropin (Growth Hormone)
Somavert
Suboxone
Xolair
Zyflo

Last updated: 01/25/2008