Pharmacy information

Pharmacy forms

Prescription Claim Form [pdf]
Prescription Mail Service Order Form [pdf]
If your policy has a mail-order drug benefit, use this form to order new and/or refill mail service prescriptions.
Prior Authorization Form for Prescription Drugs [pdf]
Information contained in this form is Protected Health Information under HIPAA Complete/review information, sign and date. Fax signed forms to CVS/Caremark at 855-245-2134 for prior authorization, step therapy, and quantity limit requests. Contact CVS/Caremark at 855-582-2022 with questions regarding the step therapy, prior authorization and quantity limit review process. For Non-Formulary Exception requests, fax the form to 501-378-6980. For Non-Formulary Exception request questions, contact 501-378-3392.

Using your pharmacy benefits
How to use your benefits and the advantages your pharmacy plan offers you.
View pharmacy claims in Blueprint Portal
Your prescription claims history, including prescription number, date filled, prescriber, quantity, pharmacy, amount paid by you and amount paid by your pharmacy plan. To access information about your personal pharmacy claims, you must register to use Blueprint Portal, our member self-service center.
Network pharmacy search
Drug pricing
- Complete Plus plan (copay plan)
  $20/$50/$75 / $1,000 Max Allowable Benefit (MAB)
- Complete plan (HDHP plan)
  $2,500 Individual/$5,000 Family deductible, 20% coinsurance / $1,000 Max Allowable Benefit (MAB)
Save money on medications
How to read labels
Generic medications
Specialty drugs
Step Therapy Clinical Documentation
Free immunizations at pharmacy

For those members with mail-order drug benefit, an online service is available, which allows you to:

For more information, navigate to the pharmacy site on Blueprint Portal. Or download and complete the paper form. [pdf]