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Forms and Translated Materials

Print

Appointment of Representative
Authorization to Disclose Protected Health Information
Automated Premium Payment (ACH) Form
Prescription Drug Mail-Order Form
Prescription Drug Claim Form
Prior Authorization
Request for Medicare Prescription Drug Coverage Determination Form
Request for Redetermination of Medicare Prescription Drug Denial Form
Physician Fax Form
File a Grievance
Appeal Instructions
Step Therapy Form

Alternate formats for these materials, including Spanish translations, may be available. Please contact our Product Specialists for additional information.

Este material está disponible en otros formatos, incluida la traducción al Español. Contacte nuestro numero de Servicio al Cliente para obtener información adicional.

Materials in English	Materiales en Español
Summary of Benefits   H1666_TX_BEN_BNFTSMRY13 Accepted 09152012	Summary of Benefits en Español  H1666_TX_BEN_BNFTSMRY13SPA Approved 09152012
Drug List   H1666_MRK_TX_TMP_FRMLRY13 Accepted 09282012	Drug list en Español   H1666_MRK_TX_TMP_FRMLRY13SPA
Pharmacy Directory   H1666_BEN_TMP_RXDRCTRY13a Accepted 10012012	Pharmacy Directory en Español H1666_BEN_TMP_RXDRCTRY13aSPA Accepted 10012012
Evidence of Coverage - Plan 001 H1666_BEN_TX_EOC0012013 Accepted 09042012	Evidence of Coverage - Plan 001 en Espanol H1666_BEN_TX_EOC0012013SPA
Evidence of Coverage - Plan 002 H1666_BEN_TX_EOC0022013 Accepted 09042012	Evidence of Coverage - Plan 002 en Espanol H1666_BEN_TX_EOC0022013SPA
Evidence of Coverage - Plan 003 H1666_BEN_TX_EOC0032013 Accepted 09042012	Evidence of Coverage - Plan 003 en Espanol H1666_BEN_TX_EOC0032013SPA Accepted 09042012