Our Pharmacy and Therapeutics Committee reviews drug classes and selects preferred agents. Please refer to the Preferred Drug List (PDL) in the printable PDF format or use our searchable PDL feature for the most up-to-date information on preferred agents for specific drug classes. Some drug products we list in the PDL require prior authorization.

MedImpact medication request forms

Please submit all pharmacy prior authorization requests to our pharmacy benefit manager, MedImpact Healthcare Systems. Please use one of the drug- or drug-class-specific MedImpact medication request forms below if applicable. For other drug prior authorization requests, please use the general MedImpact Medication Request Form (PDF). You can fax the appropriate MedImpact medication request form to 877-501-1059 or 858-790-7100.

• Cymbalta (duloxetine) Medication Request Form (PDF)
• HMG-CoA Reductase Inhibitors Medication Request Form (PDF)
• MedImpact Medication Request Form (PDF)
• Non-sedating Antihistamines Medication Request Form (PDF)
• Proton Pump Inhibitors Medication Request Form (PDF)
• Sphingosine 1-Receptor Modulators Medication Request Form (PDF)
• Synagis (palivizumab) Medication Request Form* (PDF)
• Vivitrol (naltrexone) Medication Request Form* (PDF)

*As of January 1, 2012, Caremark is no longer reviewing prior authorization requests for specialty pharmacy products such as Synagis and Vivitrol. Please fax all pharmacy prior authorization requests, including requests for specialty pharmacy products, to MedImpact at 877-501-1059 or 858-790-7100.

Caremark enrollment forms

To request specialty medications, please fax the Caremark enrollment form to 800-323-2445.

• Caremark Enrollment Form (PDF)