For Members

Direct Member Reimbursement (printable)

ID Card Replacement (online)

Mail Service Refill / Order (printable)

Mail Service Refill / Order (online)
Use this form to order prescriptions through the PBM Plus Mail Service Pharmacy

Mail Service Enrollment (printable)

Mail Service Enrollment (online)
Use this form to apply for independent prescription coverage through the PBM Plus discount prescription plan

Mail Service Acknowledgement of Receipt of Privacy Statement (printable)

For Clients

Benefit Change (printable)

For Pharmacists

Prior Authorization Request (printable)

5.1 Payer Sheet (printable)

Pharmacy Network Agreement (printable)

For Physicians

Prior Authorization Request (printable)