Click the name of the form to view each document.
Use this form to appoint any individual (such as a relative, friend, advocate, attorney, physician or other prescriber, or an employee of a pharmacy, charity, state pharmaceutical assistance program, or other secondary payer) to act as your representative for Coverage Decisions and/or Appeals.
Prescription Drug Claim Form
Request reimbursement for prescription drugs by completing this form.
Prescription Drug Mail Order Form
Request your maintenance prescription drugs to be mailed to you through our ReadyFill at Mail® mail order program.
Use CMS’s form to request a coverage determination for a prescription drug. (e.g., Request for Prior Authorization, Tiering Exception, or a Non-Formulary Drug Exception.)
Request for a Medicare Prescription Drug Coverage Determination - Online
Speed up your request for a prior authorization, tiering exception or to request coverage for a drug not on our formulary by using this “online” form to electronically request a coverage determination for a prescription drug.
If you prefer, download our Request for a Medicare Prescription Drug Coverage Determination to request a prior authorization, tiering exception, or to request coverage for a drug not on our formulary. Click to download the form, complete it and mail or fax it to us.
Request for a Redetermination of a Denial of Prescription Drug Coverage (Appeal for Prescription Drug Services) – Online
Speed up your request to appeal our denial of coverage and/or payment of a Prescription Drug by using our “online” form to electronically request your appeal.
If you prefer to download our Request for Redetermination of a Denial of Prescription Drug Coverage, just click on the form to download, complete and mail or fax it to us.