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Forms

For Self-Funded Members with PAI Drug Coverage with CVS Caremark

Prescription Drug Claim Form

Members should use the Prescription Drug Claim form to file claims for covered prescriptions for which they paid 100 percent, for covered prescriptions they received without showing their ID card, and for covered prescriptions they received from a non-participating pharmacy. 

Prescription Drug Mail Service Form

Members should use the Prescription Drug Mail Service form to order up to 90-day supplies of their prescriptions through Caremark's Mail Service prescription drug program. On behalf of PAI, Caremark assists in the administration of the program. Caremark is an independent company that provides pharmacy benefits management.

Please Note: Not all of our members have mail-service prescription drug benefits. They should check their health plan details or ask their benefits coordinators to make sure they have mail-service benefits.