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
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