Useful Forms

Mail Order Form

Receive your drug prescriptions through the mail.

Mail completed form to:

• MedImpact Direct
• P.O. Box 51580
• Phoenix, AZ 85076-1580

Mail Order Form

Request for Medicare Prescription Drug Coverage Determination

Request a coverage determination, including a request for tiering or formulary exception.

Mail completed form to:

• TEAMStar Medicare Part D Prescription Drug Program (PDP)
• P.O. Box 8080
• McKinney, TX 75070

Direct Member Reimbursement Form

Download this form to request reimbursement for a covered prescription drug you purchased at retail cost.

Mail completed form to:

• MedImpact Healthcare Systems, Inc.
• P.O. Box 509108
• San Diego, CA 92150-9108
• Fax: 858-549-1569
• E-mail: Claims@Medimpact.com

Direct Member Reimbursement Form

Hospice Status Form and Instructions

Use this form to communicate members’ Hospice status and unrelated medication overrides.

Fax to the number listed on the form.

Hospice Status and Plan of Care Form

Appointing a Representative Form

Download this 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.

Mail completed form to:

• TEAMStar Medicare Part D Prescription Drug Program (PDP)
• P.O. Box 8080
• McKinney, TX 75070

Appointing a Representative Form

Downloadable Enrollment Form

Download an enrollment form that can be filled out by hand and mailed in to our offices.

TEAMStar Enrollment Form