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Pharmacy Forms

PDF  Prescription Drug/COVID-19 At-Home Test Kit Claim Form

Use this claim form to submit eligible pharmacy expenses for reimbursement, including COVID-19 at-home test kits you paid out of pocket for. You have to submit one claim form for each person and each prescription. Full instructions can be found on page 2. ID: 3272 NJ 03/22

PDF  Mail Service Pharmacy Registration & Order Form (Spanish) – AllianceRx Walgreens Prime by Walgreens Mail Service

Use este formulario para inscribirse/remitir su primera orden de receta.

PDF  Mail Service Registration & Prescription Order Form – AllianceRx Walgreens Prime by Walgreens Mail Service

Use this form to register or submit your first prescription order. ID: W0319-1118

PDF  Medicare Claim Form

Claim form for Medicare Part D prescriptions. ID: 2875

PDF  Request Form - Determination of Medicare Prescription Drug Coverage

Members who want exceptions to the Medicare prescription formulary and/or to copay tiering can use this form to request a Medicare prescription drug coverage determination. ID: H3154

PDF  Request Form - Redetermination of Medicare Prescription Drug Denial

Members who want exceptions to the Medicare prescription formulary and/or to copay tiering can use this form to request a Medicare prescription drug coverage determination. ID: H3154