Useful Forms

Mail Order Form
 

Receive your drug prescriptions through the mail.
Click here to download the Mail Order Form.

Mail completed form to:
Prescription Solutions
P.O. Box 509075
San Diego, CA  92150-9075

 
     
Request for Medicare Prescription Drug Coverage Determination
 

Request a coverage determination, including a request for tiering or formulary exception.
Click here to download the Request for Medicare Prescription Drug Coverage Determination Form.

Mail completed form to:

TeamStar Medicare Part D
PO Box 8080
McKinney, TX 75070
     
Appointing a Representative Form
 

To appoint someone to act on your behalf when requesting a coverage determination. You can name a relative, friend, advocate, doctor, or anyone else to act for you. Some 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.
Click here to download the Appointing a Representative Form.

Mail completed form to:

TeamStar Medicare Part D
PO Box 8080
McKinney, TX 75070
     
Direct Member Reimbursement Form
 

To request reimbursement for a covered prescribed presription drug you purchased at retail cost.
Click here to download the Direct Member Reimbursement Form.

Mail completed form to:

Prescription Solutions
PO Box 29046
Hot Springs, AR 71903
     

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.

updated 10/1/09

This website is intended to provide you with information about Medicare prescription drug coverage so you can make an informed decision about how Medicare Part D can help you manage your prescription drug costs. The International Brotherhood of Teamsters Voluntary Employee Benefits Trust is a Medicare-approved Part D Sponsor.