PBM Plus Pharmacy Benefits Management
    
 
Printable Forms
All printable forms in pdf format require Acrobat Reader.

For Members with Employer-Sponsored Coverage

OMNICARE EMPLOYEES
  For all enrollment and benefits questions including:
  • Co-pays
  • Inclusions/Exclusions
  • Prior Authorizations
  • Direct Member Reimbursements
Contact CLARITY at 1-800-350-6714

Submit a new prescription or refill request to the PBM Plus Mail Order Pharmacy
  Mail Service Refill / New Order (printable)
Mail Service Refill / New Order (online)


Privacy Statement
  Mail Service Acknowledgement of Receipt of Privacy Statement (printable)

Apply for Direct Member Reimbursement (not for Omnicare Employees)
  Direct Member Reimbursement (printable)

Request a replacement ID card (not for Omnicare Employees)
  ID Card Replacement (online)

For Individuals NOT Covered by an Employer-Sponsored Pharmacy Plan
Enroll for independent prescription coverage through the PBM Plus Mail Service discount prescription plan
  Mail Service Discount Plan Enrollment (printable)
Mail Service Discount Plan Enrollment (online)


Privacy Statement
  Mail Service Acknowledgement of Receipt of Privacy Statement (printable)

For Clients
Form for Benefit Change
  Benefit Change (Printable)

For Pharmacists
Form to Request a Prior Authorization
  Prior Authorization Request (printable)

Payer Sheet
  5.1 Payer Sheet (printable)

Pharmacy Network Agreement
  Pharmacy Network Agreement (printable)

For Physicians
Form to Request a Prior Authorization
  Prior Authorization Request (printable)

 
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Office: 300 TechneCenter Dr, Suite B, Milford OH 45150 . Phone: 888-863-1726 . Contact Us