Useful Forms
Click on form name to access and download.
Appointing a Representative Form
If you wish to appoint someone to act on your behalf when requesting a coverage determination, use the Appointing a Representative Form. 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.
Direct Claim Form
Submit claims for medications dispensed at a nonparticipating pharmacy due to an emergency. You must submit claims within twelve (12) months of date of purchase.
Medco Mail Order
Receive your drug prescriptions through the mail.
Health & Allergy Questionnaire
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:
First United American Life Insurance Company
Group Part D Member Services
P.O. Box 8080
McKinney, TX 75070
Vaccine and Administration Form
For reimbursment of covered Part D vaccines and their administration (injection).
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