WEA Trust - Health Plan - Your Drug Plan

Prescription drug forms

Choose and click on the form you need for instant downloading and printing.

Medication checklist form
Use this form to keep track of your medications and share with your doctor and pharmacist.

	Mail-Order Form To save time, print the Mail-Order Form and send the completed form and prescription to:
	Caremark P.O. Box 3223 Wilkes Barre, PA 18773-3223

	Coordination of Benefits Prescription Drug Claim Form Use this form to submit claims under coordination of benefits (secondary coverage) rules. After completing the form, send it to the following address: Caremark P.O. Box 52136 Phoenix, AZ 85072-2136
	Prescription Claim Form Use this form if you have paid for a prescription out of pocket. After completing the form, send it to the following address: Caremark P.O. Box 52136 Phoenix, AZ 85072-2136
	Foreign Claim Form Use this form for prescriptions that were purchased outside the United States or on a cruise ship. After completing the form, send it to the following address: Caremark P.O. Box 52136 Phoenix, AZ 85072-2136

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