Prescription Drug Forms

Mail Order Form

Use this form to order medication through our mail order service (MEDCO BY MAIL).  If you need additional information or assistance, call Pharmacy Customer Service at the phone number on your ID card.

Summit Plans
Advantra Plans

Coordination of Benefits Direct Claim Form

Use this form to submit claims under Coordination of Benefit Rules.

Summit Plans
Advantra Plans

Vaccine & Administration (Injection) Claim Form

This claim form is for reimbursement of covered Part D vaccines and their administration (injection). Please consult your Evidence of Coverage for specific coverage information.

Summit Plans
Advantra Plans

Medco Health, Allergy & Medication Questionnaire (HMQ)

Your answers to the following questions will help protect you against potentially harmful drug interactions and side effects. Medco will alert your pharmacist about possible drug allergies and interactions that can be harmful. To best serve you, Medco needs you to answer the questions in this questionnaire.

Summit Plans
Advantra Plans

www.medco.com

If you wish to order prescriptions online please go to www.medco.com to register and order.

Coverage Determination Form

You must contact us if you would like to request a coverage determination by completing and returning this form.  Send your completed form to the following address: VISTA/Summit Pharmacy Department, Coverage Determinations, 1340 Concord Terrace, Sunrise FL 33323.

Coverage Redetermination Form

You must contact us if you would like to request a coverage redetermination by completing this form

2010 Step Therapy Protocol

Step therapy protocol information

Quantity Limits

Quantity limits on prescription drugs

2010 Prior Authorization Criteria

Prior Authorization Criteria Information

Prior Authorization Forms

• Actiq and Fentora
• Anticoagulant
• Antihistamines
• Apokyn
• Aranesp
• Avonex/Betaseron/Rebif
• Copaxone
• Enbrel
• Formulary Exception
• Forteo
• General Prior Authorization
• Gleevec
• Hepatitis C
• Humira
• Immunosuppresant
• Itraconazole
• Lipitor
• Neupogen/Leukine/Neulasta
• Oxycodone ER and Oxycontin
• Procrit and Epogen
• Proton Pump Inhibitor
• Quantity Exception
• Revlimid
• Symlin
• Tarceva
• Testosterone
• Thalomid
• Tier Cost Sharing Exception Form
• Tracleer
• Xalatan
• Xolair
• Zavesca