Useful Forms

Mail Order Form

Receive your drug prescriptions through the mail.

Mail completed form to:

  • MedImpact Direct
  • P.O. Box 51580
  • Phoenix, AZ 85076-1580
Mail Order Form

Request for Medicare Prescription Drug Coverage Determination

Request a formulary exception, a tiering exception, a prior authorization for a drug, or file an appeal.

Mail completed form to:

  • Teamster Plus Medicare Part D Prescription Drug Program (PDP)
  • P.O. Box 8080
  • McKinney, TX 75070

Request for Medicare Prescription Drug Coverage Determination

Direct Member Reimbursement Form

Download this form to request reimbursement for a covered presription drug you purchased at retail cost.

Mail completed form to:

  • MedImpact Healthcare Systems, Inc.
  • P.O. Box 509108
  • San Diego, CA 92150-9108
  • Fax: 858-549-1569
  • Email: Claims@Medimpact.com
Direct Member Reimbursement Form

Hospice Status Form and Instructions

Use this form to communicate members’ Hospice status and unrelated medication overrides.

Fax to the number listed on the form.

Hospice Status and Plan of Care Form

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.

Mail completed form to:

  • Teamster Plus Medicare Part D Prescription Drug Program (PDP)
  • P.O. Box 8080
  • McKinney, TX 75070

Appointing a Representative Form

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.

Part D with Other Plans

Contact Us

For your Medicare Part D questions and needs, please let us know how we can assist you.

Locate a Pharmacy

Pharmacy Locator

Visit a Union Designated Pharmacy to get generic drugs at a low cost or find a retail pharmacy near you.

Pill

Formulary

Browse our Formulary and see if we cover your prescription drug needs.