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 assesment
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.
Use this form to request coverage for a brand name drug. You’ll need the doctor to fill in some sections.
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.