If you have coverage through your employer or plan sponsor, use our workplace benefits insurance forms. If you have coverage through an advisor, use our personal insurance forms.
Use this form to request coverage of a brand name drug.
Download this form and print it, or fill it out in Adobe Reader XI or higher (not your browser) and save.
Step 2: Ask your doctor to complete the physician information section.
Step 3: Submit your form.
You’ll find instructions on how to submit your request on the form itself.