PHARMACY

MedGeneration Rx Claim Form

Member completes this form to request reimbursements for eligible Part D covered prescription drugs provided by a non-network pharmacy.

MedImpact Claim Form

This form is completed by the member for reimbursements for a prescription paid by a member.

MedImpact Compound Prescription Appeal Form

If your compound prescription claim(s) rejected or denied at your pharmacy, you may request an appeal by completing this form.

MedImpact Prescription Appeal Form

This form is completed by the member and the pharmacy for a prescription claim(s) rejected or denied at the pharmacy that you are appealing.