Pharmacy Forms & Notices

Here’s a list of pharmacy documents and forms you may need when using your Medicare Part D benefit. If you have questions about these items, please contact Member Services. We’re here to help.

• Prescription Drug Claim Form-English (PDF)
• Prescription Drug Claim Form-Spanish (PDF)

• Express Scripts Mail Order Form-English (PDF) - Coming in December 2023
• Express Scripts Mail Order Form-Spanish (PDF) - Coming in December 2023

• Covered Diabetes Testing Supplies - (PDF)

• List of Drugs (Formulary)

• List of Drugs Change Notice

• Drug Coverage Determination (Exception)

• Drug Redetermination (Appeal)

• Part D Prior Authorization Criteria Form

• Part D Step Therapy Criteria Form

• Appointment of Representative Form- English (PDF)
• Appointment of Representative Form- Spanish (PDF)

Pharmacy Forms & Notices

Here’s a list of pharmacy documents and forms you may need when using your Medicare Part D benefit. If you have questions about these items, please contact Member Services. We’re here to help.