Useful Forms
Direct Claim Form
Submit claims for medications dispensed at nonparticipating pharmacy due to an emergency. You must submit claims within three (3) months of date of purchase.
Medco Mail Order / Health & Allergy Questionnaire
Receive your drug prescriptions through the mail.
Request for Medicare Prescription Drug Coverage Determination Form
Request formulary or tiering exception, prior authorization for a drug, or file an appeal.
Note: Drugs may be added or removed from our Formulary during the year. You will be notified at least 60 days before the date that the change becomes effective.
Coverage Review Fax Form
If one of your patients or a pharmacist requests help in completing a coverage review, you can start the process by fax using the Coverage Review Fax Form.
To initiate the review by phone, contact Medco at: 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 by 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.
Mail completed form to:
First United American Life Insurance Company
Attn: Part D Silver Information
P.O. Box 8080
McKinney, TX 75070
Vaccine and Administration Form
This form is for reimbursment of covered Part D vaccines and their administration (injection).
Note: You must have Adobe Reader version 5.0 or higher installed on your computer in order to view and print the above file properly. Click here to download a FREE COPY of Adobe Reader.
