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
Medicare Prescription Drug Coverage Determination Request Form
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
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.