Print and complete the request for brand name drug coverage form.
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.
Select the Request for Brand Name Drug Coverage form.