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Request coverage for a brand name drug

Have coverage through your employer or plan sponsor? You’re in the right place.

If you have coverage through an advisor, use our personal insurance formsOpens in a new window instead.

Request an assessment

Use this form to request coverage of a brand name drug. 

Step 1: Complete a form

Download this form and print it, or fill it out in Adobe Reader XI or higherOpens a new website in a new window - Opens in a new window  (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.

Not what you’re looking for? Find the forms you need.

I have coverage through my employer

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I bought coverage through an advisor

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