Forms

Effective September 1, 2008
Caremark is Your New Prescription Drug Administrator

These claim forms should be used when filing for reimbursement for a prescription drug or when using the mail-order program for services rendered on or after September 1, 2008.

• Prescription Drug Reimbursement Form (pdf)
• Prescription Drug Mail-Order Form (pdf)

For information on your new Prescription Drug Administrator, refer to ERS' communications.

• ERS' letter to all HealthSelect Members, sent July 2008 (pdf)
• Time to Learn about Caremark (pdf)

If you need assistance in completing your prescription drug forms, please contact Caremark Customer Service at (888) 886-8490.

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Medco
Prior to September 1, 2008, Medco was your Prescription Drug Administrator.  For services received prior to September 1, 2008, use the forms below for Medco.

• Prescription Drug Reimbursement Form (pdf)
• Prescription Drug Mail-Order Form (pdf)

If you need assistance in completing your prescription drug forms, please contact Medco Customer Service at (800) 903-8345.