Pharmacy Benefit Management Forms

Coverage requests

To request coverage for a medication that requires prior approval before we will pay for it, have your provider fill out a coverage request form: 

Authorization Request Form

Fertility Agent Request Form

Grievance/Appeal Form

Reimbursement requests

For prescriptions that you paid for but were unable to have billed to your prescription insurance, fill out a reimbursement request form:

Reimbursement Request Form

Reimbursement Request Form- Compound Claims


For concerns regarding services, call us at the number on the back of your card or fill out a complaint form:

Grievance/Appeal Form