Prescription Drug Forms

The following prescription drug forms are available as PDF files. Just click on a form to download it. Have your doctor fax in completed forms at 1-877-243-6930. Your doctor can submit online or call 1-855-457-0407. You will need Adobe Reader to view these files; this can be downloaded free of charge at Adobe's site.



Find a Doctor or Hospital

Use our Provider Finder® to search for doctors and other health care providers near you.

Contact Us