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REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION This form may be sent to us by mail or fax Address CVS Caremark MC109 P. Can get the number of pills my prescriber prescribed formulary exception. My drug plan charged me a higher copayment for a drug than it should have. Contact us to learn how to name a representative. Enrollee s Information Enrollee s Name Date of Birth Enrollee s Address City State Zip Code Phone Enrollee s Member ID Complete the following section ONLY if the...

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