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Get Caremark 91-005481

Date, and FAX to Caremark. Section I: Plan Participant Information – (Print Clearly) Name: Date of Birth Cardholder ID #: Address: City: State, Zip: Day Telephone: Evening Telephone: Section II: Doctor Information – (Print Clearly) Doctor Name: Address 1: Telephone: Address 2: Fax: City: State, Zip: Section III: Name of generic medicine that you are appealing Medicine Name: Dosage Form: Medicine Strength: Diagnosis: Section IV: Doctor Questionnaire Please circle “Yes” or “N.

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