Benefits Forms: Prescription Drug Plan Forms
IMPORTANT: All of the forms listed on these pages are in Adobe
Portable Document Format (PDF). If you do not already
have Adobe Acrobat Reader on your computer, you must download
and install Adobe
Acrobat Reader before you will be able to view
or print Benefits forms.
- NoviXus Pharmacy Services mail service enrollment form
- Temporary Drug Plan ID Card
- Prescription Drug Claim Form (MedImpact)
- Multiple Rx Claim Form (MedImpact)
- Compound Prescriptions Claim Form (MedImpact)
- Prior Authorization Appeal Request Form (contact MedImpact Member Service at 1-800-681-9578)
- Pocket Medication Record
For you to list your prescription and non-prescription medications and emergency contact information.
Every effort has been made to ensure the accuracy of the benefits information in this site. However, if any provision on the benefits plans is unclear or ambiguous, the Benefits Office reserves the right to interpret the plan and resolve the problem. If any inconsistency exists between this site and the written plans or contracts, the actual provisions of each benefit plan will govern. The University of Michigan in its sole discretion may modify, amend, or terminate the benefits provided with respect to any individual receiving benefits, including active employees, retirees, and their dependents.