Please complete one form per Medicare Prescription Drug you are requesting a Coverage Determination for.

This form may also be sent to us by mail or fax:


CVS Caremark
Appeals Dept.
PO Box 52000
Phoenix, AZ 85072-2000

Fax: 1-855-633-7673

You may also ask us for a coverage determination by phone at 1-888-486-3326 (TTY 711), 24 hours a day, 7 days a week, or through our website

For questions regarding the coverage determination process, please call the customer support number on your prescription card.

Enrollee's Information

Who may make a request: Your prescriber may ask us for a coverage determination on your behalf. If you want another individual (such as a family member or friend) to make a request for you, that individual must be your representative. Contact us to learn how to name a representative.


* Indicates required information.

Requestor Information (if not Enrollee - Prescriber, Family Member or Friend)

Complete the following section ONLY if the person making this request is not the enrollee or prescriber:

** Representation documentation for requests made by someone other than enrollee or the enrollee's prescriber. Attach documentation showing the authority to represent the enrollee (a completed Authorization of Representative Form CMS -1696 or a written equivalent). For more information on appointing a representative, contact your plan or 1-800-Medicare

Prescription drug you are requesting:

Have you purchased the drug pending appeal?

* Note: If you are asking for a formulary or tiering exception, your prescribing physician MUST provide a statement to support your request. Requests that are subject to prior authorization (or any other utilization management requirement), may require supporting information. Your prescriber may also use the "Supporting Information for an Exception Request or Prior Authorization" to support your request.

Important Note: Expedited Decisions

Supporting Information for an Exception Request or Prior Authorization

Prescriber Information

Diagnosis and Medical Information

Attachments (JPG, PDF, or TIF up to 10 megabytes)

You can submit up to five (5) attachments as supporting documentation. Limit 10 megabytes allowed per prescription drug coverage determination request. If you have other drugs you would like to request a coverage determination request for, please submit a form for each. To save your document into a .jpg or a .tif, go to file, save as, and save it with the extension of your choice. If you are scanning in a document, it is possible your scanner will save it in a .pdf format.

An electronic signature is required on this request. Clicking the grey submit button below, will serve as your electronic signature.