Benefits Forms: Prescription Drug Plan Forms
IMPORTANT: All of the forms listed on these pages are in Adobe
Portable Document Format (PDF). If you do not already
have Adobe Acrobat Reader on your computer, you must download
and install Adobe
Acrobat Reader before you will be able to view
or print Benefits forms.
- NoviXus Pharmacy Services mail service enrollment form
- Temporary Drug Plan ID Card
- Prescription Drug Claim Form (MedImpact)
Please note: Claims will not be reimbursed if received after 90 days from the date of the prescription fill.
- Multiple Rx Claim Form (MedImpact)
- Compound Prescriptions Claim Form (MedImpact) Click here for details on coverage of compound prescriptions.
- Prior Authorization Appeal Request Form (contact MedImpact Member Service at 1-800-681-9578)
- Pocket Medication Record
For you to list your prescription and non-prescription medications and emergency contact information.