Forms Library
Generic Pricing MAC Appeal Form
Submit a request for review of a maximum allowable cost (MAC) pricing decision.
Internal Appeal Request Form
Allows you to ask your health plan to review and reconsider a denied claim or coverage decision.
Internal Appeal Request Form - Second Level
Request a higher-level review after an initial appeal isn’t approved.
Standard Appeal Form
Submit a formal request for review of a denied claim or coverage decision.
Medical Exception Request Form - Quantity Override
Request the ability to prescribe more of the approved product.
Medical Exception Request Form - Non-Formulary
Request coverage for a medication that isn’t on your plan’s approved drug list.
Medical Exception Request Form - Costs Exceeds Maximum
Request coverage for a medication that cost exceeds maximum
Medical Exception Request Form - Tiering Exception
Request a lower copay tier for a covered medication when medically necessary.
Quantity Limit Medical Necessity Request Form
Request approval for a higher amount of medication than your plan normally covers.
Quantity Limit Medical Necessity – Proton Pump Inhibitors
Request a higher quantity for a PPI medication due to medical necessity.
Step Therapy Medication Medical Necessity Form
Request to bypass step-therapy requirements due to medical necessity.
PPC Mail Order
Mail Order Pharmacy Program Registration and Order form.
Spanish PPC Mail Order
Formulario de registro y pedido del programa de farmacia por correo.
Walgreens Mail Order registration
To place a mail order through the Walgreens processing center, please download the form using the link above and fill out all required information before submitting it via mail.
Walgreens Mail Order Physician Fax
To order through Walgreens, please download the Walgreens Prescriber Fax Form using the link above and fill out all required information before submitting it via fax.
Prior Authorization
PHYSICIAN CERTIFICATION PRIOR AUTHORIZATION FORM.
Prescription Reimbursement Form
Submit for reimbursement if you purchase your medications outside the plan’s mail-order pharmacy.
Covered Persons Rights & Responsibilities
Overview of your rights and responsibilities as a plan member.
General MAC Appeal Form
Use this form to request a review of Maximum Allowable Cost (MAC) pricing and ensure accurate reimbursement for covered medications.
Treating Physician Certification
Treating Physician Certification for Internal Appeal and/or External Review.
Enrollment Form
Form used to enroll in or register for pharmacy benefit programs.
Medicare Creditable Coverage Notice
Informs members that prescription drug coverage is considered creditable under Medicare Part D.
Medicare Non-Creditable Coverage Notice
Notifies members that prescription drug coverage is not considered creditable under Medicare Part D.
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