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If you need a copy of a particular form, ConnectiCare's Online Form Resource can save you time. To obtain a copy of a specific pharmacy form, please click on the form by name below. A description and directions for use will appear. If you are looking for a form not listed here, please go to the member forms or provider forms.

All forms are in PDF format. The freely available Adobe Acrobat reader is required to view and print PDF files.

  1. Prescription Drug Reimbursement Claim Form
  2. Prescription Drug Mail Pharmacy Order Form
  3. Pharmacy Pre-Authorization Form: Antidepressants
  4. Pharmacy Pre-Authorization Form: General Requests
  5. Pharmacy Pre-Authorization Form: Celebrex
  6. Pharmacy Pre-Authorization Form: Cimzia
  7. Pharmacy Pre-Authorization Form: Fibromyalgia and Other Neuropathic Pain
  8. Pharmacy Pre-Authorization Form: Physician Administered Drugs
  9. Pharmacy Pre-Authorization Form: Proton Pump Inhibitors
  10. Pharmacy Pre-Authorization Form: Statin Medications
  11. Pre-Authorization Form: Infertility Therapy
  12. Pharmacy Pre-Authorization Form: Testosterone Replacement Therapy
  13. Pharmacy Pre-Authorization Form: Hepatitis C

* All forms are the exclusive property of ConnectiCare, or used by ConnectiCare with permission, and protected by copyright. All forms are to be used solely for business with ConnectiCare.

 

Form Use this form... Directions for Use
Prescription Drug Reimbursement Claim Forms

ConnectiCare, Inc.

ConnectiCare of Massachusetts, Inc.

ConnectiCare of New York, Inc.

 If you are seeking to receive reimbursement for prescriptions that were purchased without the use of your ConnectiCare ID Card.
  • Print the form.
  • Fill in the appropriate information.
  • Attach all receipts.
  • Mail the information to: ConnectiCare, Claims Dept., P.O. Box 546, Farmington, CT 06034.
  • If you have any questions, call ConnectiCare’s Member Services Dept. at 1-800-251-7722, 8:00 a.m. to 6:00 p.m. Monday through Thursday, and 8:00 a.m. to 5:00 p.m. on Fridays, Eastern Time.

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Form Use this form... Directions for Use
Prescription Drug Mail Pharmacy Order Form If you are seeking to order a 90-day supply of maintenance prescription drugs through the mail.
  • Print the form.
  • Fill in the appropriate information.
  • Attach the prescription from your provider.
  • Enclose your payment.
  • Mail the information to Express Scripts, Attn: Mail Pharmacy, 3684 Marshall Lane, Bensalem, PA 19020-5914.
  • If you have any questions, the Express Scripts' Customer Service Call Center, available 24 hours-a-day, 365 days-a-year at 1-800-369-0675.

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Form Use this form... Directions for Use
Pharmacy Pre-Authorization Form: Antidepressants If you are seeking to obtain authorization for antidepressant medications.
  • Fill in the form online.
  • Print the completed form.
  • Fax the completed form to Pharmacy Services (860) 674-2851 or mail to ConnectiCare, Attn: Pharmacy Services, 175 Scott Swamp Road, Farmington, CT 06032-3124.
  • If you have any questions, call ConnectiCare’s Member Services Dept. at 1-800-251-7722, 8:00 a.m. to 6:00 p.m. Monday through Thursday, and 8:00 a.m. to 5:00 p.m. on Fridays, Eastern Time.

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Form Use this form... Directions for Use
Pharmacy Pre-Authorization Request Form: General Requests If you are seeking to obtain authorization for medications other than certain specific drugs that require their own form, as listed above.
  • Fill in the form online.
  • Print the completed form.
  • Fax the completed form to Pharmacy Services (860) 674-2851 or mail to ConnectiCare, Attn: Pharmacy Services, 175 Scott Swamp Road, Farmington, CT 06032-3124.
  • If you have any questions, call ConnectiCare’s Member Services Dept. at 1-800-251-7722, 8:00 a.m. to 6:00 p.m. Monday through Thursday, and 8:00 a.m. to 5:00 p.m. on Fridays, Eastern Time.

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Form Use this form... Directions for Use
Pharmacy Pre-Authorization Request Form: Celebrex If you are seeking to obtain authorization for Celebrex.
  • Print or save form.
  • Fill in the appropriate information.
  • Fax the completed form to Pharmacy Services (860) 674-2851 or toll free (800) 249-1367 or mail to ConnectiCare, Attn: Pharmacy Services, 175 Scott Swamp Road, Farmington, CT. 06032-3124.
  • If you have any questions, call ConnectiCare's Member Services Dept. at 1-800-251-7722, 8:00 a.m. to 6:00 p.m. Monday through Thursday, and 8:00 a.m. to 5:00 p.m. on Fridays, Eastern Time.

 

Form Use this form... Directions for Use
Pharmacy Pre-Authorization Form: Cimzia If you are seeking to obtain authorization for Cimzia.
  • Print the form.
  • Fill in the appropriate information.
  • Fax the completed form to Pharmacy Services (860) 674-2851 or mail to ConnectiCare, Attn: Pharmacy Services, 175 Scott Swamp Road, Farmington, CT. 06032-3124.
  • If you have any questions, call ConnectiCare's Member Services Dept. at 1-800-251-7722, 8:00 a.m. to 6:00 p.m. Monday through Thursday, and 8:00 a.m. to 5:00 p.m. on Fridays, Eastern Time.

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Form Use this form... Directions for Use
Pharmacy Pre-Authorization Form: Hepatitis C If you are seeking to obtain authorization for interferon treatment of Hepatitis C.
  • Fill in the form online.
  • Print the completed form.
  • Fax the completed form to Pharmacy Services (860) 674-2851 or mail to ConnectiCare, Attn: Pharmacy Services, 175 Scott Swamp Road, PO Box 4050, Farmington, CT 06034-4050.
  • If you have any questions, call Provider Services at 1-800-828-3407, Monday through Friday 8:00 a.m. - 5:00 p.m. Eastern Time.

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Form Use this form... Directions for Use
Pharmacy Pre-Authorization Request Form: Fibromyalgia and Other Neuropathic Pain If you are seeking to obtain authorization for Cymbalta or Lyrica for fibromyalgia or other neuropathic pain.
  • Print the form.
  • Fill in the appropriate information.
  • Fax the completed form to Pharmacy Services (860) 674-2851 or mail to ConnectiCare, Attn: Pharmacy Services, 175 Scott Swamp Road, Farmington, CT. 06032-3124.
  • If you have any questions, call ConnectiCare’s Member Services Dept. at 1-800-251-7722, 8:00 a.m. to 6:00 p.m. Monday through Thursday, and 8:00 a.m. to 5:00 p.m. on Fridays, Eastern Time.

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Form Use this form... Directions for Use
Pharmacy Pre-authorization Form: Physician Administered Drugs If you are seeking to obtain authorization for a physician administered drugs (e.g., injectable drugs).
  • Print or save the form.
  • Fill in the appropriate information.
  • Fax the completed form to Pharmacy Services (860) 674-2851 or toll free (800) 249-1367 or mail to ConnectiCare, Attn: Pharmacy Services, 175 Scott Swamp Road, Farmington, CT. 06032-3124.
  • If you have any questions, call ConnectiCare’s Member Services Dept. at 1-800-251-7722, 8:00 a.m. to 6:00 p.m. Monday through Thursday, and 8:00 a.m. to 5:00 p.m. on Fridays, Eastern Time.

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Form Use this form... Directions for Use
Pharmacy Pre-Authorization Form: Proton Pump Inhibitor If you are seeking to obtain authorization for a Proton Pump Inhibitor.
  • Fill in the form online.
  • Print the completed form.
  • Fax the completed form to Pharmacy Services (860) 674-2851 or mail to ConnectiCare, Attn: Pharmacy Services, 175 Scott Swamp Road, Farmington, CT 06032-3124.
  • If you have any questions, call ConnectiCare’s Member Services Dept. at 1-800-251-7722, 8:00 a.m. to 6:00 p.m. Monday through Thursday, and 8:00 a.m. to 5:00 p.m. on Fridays, Eastern Time.

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Form Use this form... Directions for Use
Pharmacy Pre-Authorization Form: Statin Medications If you are seeking to obtain authorization for a statin cholesterol lowering medication requiring pre-authorization.
  • Fill in the form online.
  • Print the completed form.
  • Fax the completed form to Pharmacy Services (860) 674-2851 or toll free (800) 249-1367 or mail to ConnectiCare, Attn: Pharmacy Services, 175 Scott Swamp Road, Farmington, CT 06032-3124.
  • If you have any questions, call ConnectiCare's Member Services Dept. at 1-800-251-7722, 8:00 a.m. to 6:00 p.m. Monday through Thursday, and 8:00 a.m. to 5:00 p.m. on Fridays, Eastern Time.

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Form Use this form... Directions for Use
Pre-Authorization Form: Infertility Therapy If you are seeking to obtain authorization for infertility therapy, including infertility prescription drug requests.
  • Print or save form
  • Fill in the appropriate information
  • Fax the completed form to ConnectiCare at (860)674-5893
  • If you have any questions, call ConnectiCare's Member Services Dept. at 1-800-251-7722, 8:00 a.m. to 6:00 p.m. Monday through Thursday, and 8:00 a.m. to 5:00 p.m. on Fridays, Eastern Time

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Form Use this form... Directions for Use
Pharmacy Pre-authorization Form: Testosterone Replacement Therapy If you are seeking to obtain authorization for testosterone replacement therapy.
  • Fill in the form online.
  • Print the completed form.
  • Fax the completed form to Pharmacy Services (800) 249-1367 or mail to ConnectiCare, Attn: Pharmacy Services, 175 Scott Swamp Road, Farmington, CT 06032-3124. If you have any questions, call ConnectiCare's Member Services Dept. at 1-800-251-7722, Monday through Thursday 8:00 a.m. - 5:30 p.m. and Friday 9:00 a.m. - 5:00 p.m., Eastern Time.

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