Express Scripts Pharmacy Claim Form

Use this form when you have paid full price for a prescription drug at a retail pharmacy or need to submit claims under Coordination of Benefits rules.

Medicare Prescription Drug Coordination of Benefits/Claim Form

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

ESI Universal Prior Authorization Form

This is a general prior authorization form that can be used for denials wherein the member is trying to be proactive or wants to see what the physician was/is provided.