1. This form cannot be used to request Medicare non-covered drugs.
2. Medicare non-covered drugs includes:
barbiturates, benzodiazepines, fertility drugs, prescription weight loss medication, weight gain or hair growth, over-the-counter drugs, or prescription vitamins (except prenatal vitamins and fluoride preparations).
3. This form cannot be used to request biotech or other specialty drugs for which drug-specific forms are required.
You, your appointed representative, or your doctor may use this form to request a coverage determination, including an exception, from a plan sponsor, for your Medicare Part D Coverage.
Mail this form to:
ATTN: Medicare Part D
P.O. Box 14718
Lexington, KY 40512-4718
Or, fax this form to: 1-608-741-5483
Medicare Part D Hospice Prior Authorization Information
May be called: Request for Prescription Medication for Hospice.
1. The prescribing physician (PCP or Specialist) should, in most cases, complete the form. You must send it.
2. Submit a separate form for each medication requested.
3. Provide the physician address used for notification, not just the regular mailing address (they may be the same).
Some drugs require a medical review by your health plan before you can fill a prescription. Pharmacists call this a "prior authorization." Make this process easy by bringing this form with you to your appointment.
Mail this form to:
Medical Management & Policy
120 Fifth Avenue, MC P4207,
Pittsburgh, PA 15222
Or, fax this form to: 1-866-240-8123
Prescription Drug Reimbursement Form
May be called: Medication Reimbursement Claim, Retail Prescription Claim.
Important Legal Information: Health care benefit programs are issued or administered by Highmark Blue Cross Blue Shield Delaware or Highmark Health Insurance Company, both of which are independent licensees of the Blue Cross Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. Information on this website is issued by Highmark Blue Cross Blue Shield Delaware on behalf of these companies, which serve the State of Delaware.
References to “Highmark” are references to Highmark Inc., an independent licensee of the Blue Cross Blue Shield Association, and/or to one or more of its affiliated Blue companies.