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Originator biologic drug coverage form

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

If you bought coverage through your advisor, use our personal insurance forms instead.

Request pre-approval

Use this form to request approval for originator biologic drug coverage.

Step 1: Complete a form.

Download the 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. Complete the plan member section.

Step 2: Ask your doctor to complete the physician information section.

 

Step 3: Submit your request for approval.

You’ll find instructions on how to submit your claim 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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