Useful Forms
Click on form name to access and download.
Mail Order Form
Receive your drug prescriptions through the mail.
Download the Mail Order Form (PDF file)
Mail completed form to:
Prescription Solutions
P.O. Box 29046
Hot Springs, AR 71903
Request for Medicare Prescription Drug Coverage Determination
Request a formulary exception, a tiering exception, a prior authorization for a drug, or file an appeal.
Request for Medicare Prescription Drug Coverage Determination (PDF)
Mail completed form to:
Teamster Plus Prescription Drug Plans (PDP)
PO Box 8080
McKinney, TX 75070
Request for Medicare Prescription Drug Coverage Redetermination
If your coverage determination has been denied, begin your appeal by using this form.
Request for Medicare Prescription Drug Coverage Redetermination (PDF)
Appointing a Representative Form
Download this form to appoint someone to act on your behalf when requesting a coverage determination. You can name a relative, friend, advocate, doctor, or anyone else to act for you. Some other persons may already be authorized under state law to act for you. If you want someone to act for you, then you and that person must sign and date this form.
Appointing a Representative Form (PDF)
Mail completed form to:
Teamster Plus Prescription Drug Plans (PDP)
PO Box 8080
McKinney, TX 75070
Direct Member Reimbursement Form
Download this form to request reimbursement for a covered prescribed presription drug you purchased at retail cost.
Download the Direct Member Reimbursement Form (PDF File)
Mail completed form to:
Prescription Solutions
PO Box 29046
Hot Springs, AR 71903
Note: You must have Adobe Reader version 5.0 or higher installed on your computer in order to view and print the above file properly. Click here to download a FREE COPY of Adobe Reader.
updated 10/01/11