Forms

• Claims Filing Instructions Document
• Medical Claim Form
• Caremark - Mail Service Order Form
• Caremark - RX Reimbursement Form
• Caremark - Performance Drug List - Effective 7/1/2013
• Caremark - Performance Drug List - Effective 1/1/2013
• Caremark - Formulary EX - Effective 1/1/2012
• Caremark - Formulary Drug Removals - Effective 1/1/2013
• Caremark - San Antonio Mail Order Form - Effective 1/1/2012
• Express Scripts - Prescription Drug Claim From
• Express Scripts - Prescriptions by Mail
• 2012 Express Scripts - National Preferred Formulary Listing
• 2012 Express Scripts - National Preferred Formulary Listing with contraceptives
• Dental Claim Form
• Student Certification Document
• STD Claim Form
• Disability Certification Document
• HIPAA – Authorization Form for Information Release
• HIPAA – Personal Representative Form
• HIPAA – Revocation Authorization Personal Rep Designation
• Notice of Privacy Practices