Use this form to appoint any individual (such as a relative, friend, advocate, attorney, physician or other prescriber, or an employee of a pharmacy, charity, state pharmaceutical assistance program, or other secondary payer) to act as your representative for Coverage Decisions and/or Appeals.

Prescription Drug Claim Form

Request reimbursement for prescription drugs by completing this form.

Prescription Drug Mail Order Form

Request your maintenance prescription drugs to be mailed to you through our CareMark Mail Service Pharmacy mail order program.

Request for a Medicare Prescription Drug Coverage Determination - Online

Speed up your request for a prior authorization, tiering exception or to request coverage for a drug not on our formulary by using this “online” form to electronically request a coverage determination for a prescription drug.

If you prefer, download our Request for a Medicare Prescription Drug Coverage Determination to request a prior authorization, tiering exception, or to request coverage for a drug not on our formulary.  Click to download the form, complete it and mail or fax it to us. 

Request for a Redetermination of a Denial of Prescription Drug Coverage (Appeal for Prescription Drug Services) – Online

Speed up your request to appeal our denial of coverage and/or payment of a Prescription Drug by using our “online” form to electronically request your appeal.  

If you prefer to download our Request for Redetermination of a Denial of Prescription Drug Coverage, just click on the form to download, complete and mail or fax it to us.

If you prefer to download our Request for Reconsideration Form for an independent review of your drug plan’s Denial of Prescription Drug Coverage, just click on the form to download, complete and mail or fax it to us.

Use this form to place orders for your Over-The-Counter Medications and Products. Please mail this completed form to the address at the bottom of the form.