Request coverage for a brand name drug
Have coverage through your advisor? You’re in the right place.
If you have coverage through your employer or plan sponsor, use our workplace benefits insurance formsinstead.
Request an assessment
Use this form to request coverage for a brand name drug.
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 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.