Brand name coverage form

Print and complete the request for brand name drug coverage form.

Claims and COVID-19

Due to the uncertainty of the evolving COVID-19 situation, there could be delays in processing and paying paper claims. Before you submit a paper claim, check if you can submit your claim online through GroupNet for plan members. It’s the fastest way to ensure we can process and pay your claim. Sign in and select make a claim and choose your claim type.

Please note that disability claims can’t be submitted through GroupNet. For these claims, see COVID-19 claims or standard claims.

 

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.