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