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.
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.
Use this form to request approval for originator biologic drug coverage. 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 request for approval.
You’ll find instructions on how to submit your claim on the form itself.