Useful Forms

 

Mail Order Form

Receive your drug prescriptions through the mail.
Click here to download the Mail Order Form.

Mail completed form to:

Prescription Solutions
PO Box 29046
Hot Springs, AR 71903
 

Request for Medicare Prescription Drug Coverage Determination

Request a formulary exception, a tiering exception, a prior authorization for a drug, or file an appeal.
Click here to download the Request for Medicare Prescription Drug Coverage Determination.

Mail completed form to:

Teamster Plus Medicare Part D
PO Box 8080
McKinney, TX 75070
   

Appointing a Representative 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.
Click here to download the Appointing a Representative Form.

Mail completed form to:

Teamster Plus Medicare Part D
PO Box 8080
McKinney, TX 75070
   

Direct Member Reimbursement Form

To request reimbursement for a covered prescribed prescription drug you purchased at retail cost.
Click here to download the Direct Member Reimbursement Form.

Mail completed form to:

Prescription Solutions
PO Box 29046
Hot Springs, AR 71903

 

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updated 10/1/09

This website is intended to provide you with information about Medicare prescription drug coverage so you can make an informed decision about how Medicare Part D can help you manage your prescription drug costs. The International Brotherhood of Teamsters Voluntary Employee Benefits Trust.