Forms

Members, use the forms on this page to request payment, appoint a representative, and more.

Pharmacy forms

• Coverage determination request form PDF
• Personal medication list PDF
• Mail-order prescription form PDF and brochure with directions PDF
• Request for Redetermination of Medicare Prescription Drug Denial

Other forms

• Appoint a representative PDF | Instructions
  Use this form to appoint a representative to act on your behalf regarding your appeal request.
• Prior authorization form PDF