Consumer Driven Health Plan

Caremark Forms

Mail Order Prescription form: Complete this patient profile/order form. Send this form, along with your prescription(s) and payment.

Short-Term Prescription form: If you purchase prescriptions at a non-network pharmacy, or elect to purchase additional refills at a preferred network pharmacy, or an NALC CareSelect Network pharmacy, complete the short-term prescription claim form. Mail it with your prescription receipts to the NALC Prescription Drug Program. Receipts must include the patient's name, prescription number, name of drug, prescribing doctor's name, date, charge, and name of pharmacy

OTC COVID-19 Test Reimbursement Claim F orm: If you have purchased a COVID-19 at home test, on or after January 15, 2022, and are seeking reimbursement, please print this form and submit a copy of the completed form and your receipt to the address shown on the form. If you have a account, you can also request reimbursement for at-home COVID-19 tests online. Please view this flyer for details.