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Get Caremark Prior Authorization Request Form

you a Drug Specific Prior Authorization Request Form along with the patient’s specific information and questions that must be answered. When you fax the Drug Specific Prior Authorization Request Form to us, we will review it and notify you and the patient of the result. If we deny your request, we will also provide you and the patient with the denial reason. SECTION I: PATIENT INFORMATION Last Name, First Name (PLEASE PRINT) Date of Birth (MM/DD/YYYY) Street Address Phone Number ( ) City.

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