Useful Forms
| Mail Order Form | ||||
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Receive your drug prescriptions through the mail.
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| Request for Medicare Prescription Drug Coverage Determination | ||||
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Request a coverage determination, including a request for tiering or formulary exception.
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| Appointing a Representative Form | ||||
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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.
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| Direct Member Reimbursement Form | ||||
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To request reimbursement for a covered prescribed presription drug you purchased at retail cost.
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