Useful Forms
Click on form name to access and download.
Direct Claim Form
Submit claims for medications dispensed at a nonparticipating pharmacy due to an emergency. You must submit claims within 12 months of date of purchase.
Download Direct Claim Form (PDF file)
Medco Mail Order
Receive your drug prescriptions through the mail.
Download Medco Mail Order (PDF file)
Health & Allergy Questionnaire
Download Health & Allergy Questionnaire (PDF file)
Request for Medicare Prescription Drug Coverage Determination Form
Request formulary or tiering exception, prior authorization for a drug, or file an appeal.
Note: Drugs are added or removed from our formulary during the year. You are notified at least 60 days before the date that the change becomes effective.
Download Medicare Prescription Drug Coverage Determination Form
Coverage Review Fax Form
If a patient or pharmacist requests help completing a coverage review, start the process via fax, using the Coverage Review Fax Form.
To initiate the review by phone, contact Medco at: 1-800-753-2851
Appointing a Representative Form
If you wish to appoint someone to act on your behalf when requesting a coverage determination, use the Appointing a Representative Form. You can name a relative, friend, advocate, doctor, or anyone else to act for you. Other persons may already be authorized under state law to act for you. If you want someone to act for you, then you and that person must sign and date this form.
Download Appointing a Representative Form
Mail completed form to:
Attn: Part D Member Services
P.O. Box 8080
McKinney, TX 75070
Vaccine and Administration Form
For reimbursement of covered Part D vaccines and their administration (injection).
Download Vaccine and Administration Form (PDF file)
For your Medicare Part D questions and needs, please let us know how we can assist you.
Contact Us.
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Updated 10/01/11