- Drug claim form for Medicare Part D
Use this form to submit a claim for drugs you purchased that are covered by Medicare Part D. Learn how to complete the form.
Use the forms below to request a coverage decision (sometimes called a prior authorization or an exception) if you take a drug that isn't covered by our plan. Read more about coverage decisions.
- Online coverage decision form (Note: This link takes you to an external website.)
- Printable coverage decision form
If you are appealing a previously denied coverage decision, use the forms below.
- Online coverage redetermination form (Note: This link takes you to an external website.)
- Printable coverage redetermination form
If you would like to request a coverage exception, use the applicable form below.
- Quantity limit exception form
- Step therapy exception form
- Tiering exception form
- Hospice exception form
- Update hospice status form
- Formulary (drug list) exception form
Some drugs on our drug list have step therapy requirements that must be met before we will cover the drug. Find out more about step criteria requirements for your plan below.
Some drugs on our drug list have prior authorization requirements that must be met before we will cover the drug. Find out more about prior authorization criteria requirements for your plan below.
- Prior authorization criteria - Value plan (updated 12/01/20)
- Prior authorization criteria - Standard plan (updated 12/02/20)
- Plan transition drug supply policy
If you are transitioning to a Journey Rx plan or if you take a drug that has been discontinued or is no longer on our drug list, you may be able to get a transition supply of your drug. Contact customer service with questions.
- Appoint a representative
You can choose someone to file grievances, request coverage decisions and redeterminations on your behalf.
- Authorization to release information
You can give us permission to give your protected health information (PHI) to a person or organization on your behalf.
- Confidential communication request
You can request to have member communications, including claims-related information, mailed to a different address than your permanent address.
- Our privacy practices
Learn how information about you may be used and disclosed and how you can get access to this information.