| Brand Exception Request Form |
| Non-Formulary Drug Exception Form |
| Tier Exception Form |
| Prescription Reimbursement Claim Form |
| Mail Service Pharmacy Order Form |
| MedWatch Form - To report a serious or adverse event, product quality or safety problem, etc. to the FDA |
| Virginia Members Only - Transition Fill Form |
| Maryland Members Only - Transition Fill Form |
| DC Members Only - Transition Fill Form |
Please be advised that due to planned maintenance you may experience intermittent issues between Apr 17, 2026, at 8:00 PM through Apr 20, 2026, at 6:00 AM. We appreciate your patience.
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Prescription Drug Forms
Drug
Prior Authorization