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- Find a Doctor or Pharmacy
- List of Drugs (Formulary)
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- Out-of-Network Pharmacies
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- Caregivers show Caregivers menu
On Feb. 21, 2024, Change Healthcare experienced a cyber security incident. Any individuals impacted by this incident will receive a letter in the mail. Learn more about this from Change HealthcareExternal Link, or reach out to the contact center at 1-866-262-5342.
- Shop for Plans
- I'm a Member
-
Pharmacy Benefits
-
- Find a Doctor or Pharmacy
- List of Drugs (Formulary)
- Medication Therapy Management (MTMP)
- Mail Order Service
- Specialty Pharmacy
- Coverage Determinations and Redeterminations
- Prior Authorication, Step Therapy & Quantity Limitations
- Out-of-Network Pharmacies
- Medication (Drug) Management and Safety
- Drug Transition Policy
- Pharmacy Forms
- Medicare Prescription Payment Plan
-
- Caregivers
Pharmacy Forms | Allwell from Buckeye Health Plan
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) - last updated Oct 1, 2023
- Prescription Drug Claim Form-Spanish (PDF) - last updated Oct 1, 2023
- Express Scripts Mail Order Form-English (PDF) - last updated Dec 1, 2023
- Express Scripts Mail Order Form-Spanish (PDF) - last updated Dec 1, 2023
- Covered Diabetes Testing Supplies - (PDF)External Link - last updated March 1, 2024
- Appointment of Representative Form- English (PDF)External Link - last updated Oct 1, 2023
- Appointment of Representative Form- Spanish (PDF)External Link - last updated Oct 1, 2023
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) - last updated Oct 1, 2024
- Prescription Drug Claim Form-Spanish (PDF) - last updated Oct 1, 2024
- Express Scripts Mail Order Form-English (PDF) - last updated Oct 1, 2024
- Express Scripts Mail Order Form-Spanish (PDF) - last updated Oct 1, 2024
- Covered Diabetes Testing Supplies - (PDF)External Link - last updated October 1, 2024
If you have questions, please contact Member Services.
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