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Prescriber Criteria Form 2024 PA Fax 4500A v1 010124.docx ( tablets) Coverage Determination This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax signed forms to CVS Caremark at 18667855714. Please contact CVS Caremark at 18556337673 with questions regarding the prior authorization process. When conditions are met, we will authorize the coverage of ( tablets). Drug Name:

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