Forms

» Member Forms

• Prior Authorization Form:
Members can download and print prior authorization forms for oral, topical and injectable drugs.

 

• Prescription Claim Form:
Members can download and print forms needed to submit a paper claim.

 

• Authorization for Disclosure Form:

 

 

» Pharmacy Forms

• Claims Dispute Form:
Pharmacies can download & submit for any claim which they do not agree with the remittance invoice.

 

 

» General Forms

• Analysis Data Fields For PBM Audit:
Employers can download and print data fields needed for a free PBM Plan Analysis.

 

• Business Associate Agreement: