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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) - coming soon
Prescription Drug Claim Form-Spanish (PDF) - coming soon

Express Scripts Mail Order Form-English (PDF) - coming soon
Express Scripts Mail Order Form-Spanish (PDF) - coming soon

Covered Diabetes Testing Supplies - (PDF) - coming soon

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)Oct 1, 2025
Appointment of Representative Form- Spanish (PDF)Oct 1, 2025

If you have questions, please contact Member Services.