Useful Forms
Mail Order Form
Receive your drug prescriptions through the mail.
Mail completed form to:
- Birdi, Inc.
- PO Box 8004
- Novi, MI 48376-8004
- Fax 1-877-395-4836
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.