Helping you manage pharmacy benefits Forms

Reimbursement Form

Circumstances may occur when you may be due a refund from True Rx Health Strategists for a medication not covered initially at the pharmacy. If this is the case, simply download the drug reimbursement claim form and follow the instructions. Mailing instructions are included at the bottom of the page.

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Prior Authorization Form

A Prior Authorization is the process in which information regarding a certain medication is gathered and clinically evaluated to determine if the prescription benefit plan will cover their portion of the medication cost. Some plans set limits on certain medications due to age, efficacy, cost, and availability.

If a prior authorization is needed, your doctor's office will need to complete this form. Instructions, including contact information, are included on the form.

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Appeal Form

The provider reconsideration form is used to request an appeal for providers after a coverage determination or prior authorization has been denied. This form is for your medical provider to complete with appropriate documentation and mail or fax to True Rx Health Strategists. Your doctor's office needs the address and fax number on the form.

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