Request for Brand Name Drug Coverage Form

Certain prescription drug claims need to be approved before we can consider reimbursement.

If your group benefits plan limits the reimbursement for brand name drugs to the cost of the generic drug but you have a legitimate medical reason for requiring the brand, you may request coverage for the brand name drug by submitting a completed Request for Brand Name Drug Coverage form.

1. Select the Request for Brand Name Drug Coverage form.
2. Print the form.
3. Ask your attending physician to complete it.
4. Send the completed form to us by mail or fax.

• Request for Brand Name Drug Coverage form M7088