Useful Forms
Click on form name to access and download.
Downloadable Enrollment Form
Download an enrollment form that can be filled out by hand and mailed in to our offices. Please return the completed form to:
Part D Customer Service
P.O. Box 8080
McKinney, TX 75070
Note: Online enrollment is the quickest option for enrollment processing.
Download Select Enrollment Form (PDF file)
Download Enhanced Enrollment Form (PDF file)
Electronic Funds Transfer (EFT) Information Sheet
Download Electronic Funds Transfer (EFT) Information Sheet (PDF file)
Direct Claim Form
Use this form to submit claims for medications dispensed at a nonparticipating pharmacy due to an emergency or for reimbursement of covered Part D Drugs and their administration (injection).
Download Direct Claim Form (PDF file)
Mail Order
Receive your drug prescriptions through the mail.
Download Mail Order (PDF file)
Health & Allergy Questionnaire
Download Health & Allergy Questionnaire (PDF file)
Request for Medicare Prescription Drug Coverage Determination Form
Request formulary or tiering exception, prior authorization for a drug, or file an appeal.
Note: Drugs are added or removed from our formulary during the year. You are notified at least 60 days before the date that the change becomes effective.
Download Medicare Prescription Drug Coverage Determination Form
Coverage Review Fax Form
If a patient or pharmacist requests help completing a coverage review, start the process via fax, using the
Coverage Review Fax Form.
To initiate the review by phone, Please call: 1-800-753-2851
Appointing a Representative Form
If you wish to appoint someone to act on your behalf when requesting a coverage determination, use the Appointing a Representative Form. You can name a relative, friend, advocate, doctor, or anyone else to act for you. 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.
Download Appointing a Representative Form
Mail completed form to:
Attn: Part D Member Services
P.O. Box 8080
McKinney, TX 75070
For your Medicare Part D questions and needs, please let us know how we can assist you. Contact Us.
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Updated 10/01/12