Useful Forms

Mail Order Form

Receive your drug prescriptions through the mail.

Mail completed form to:

  • OptumRx
  • P.O. Box 509075
  • San Diego, CA 92150-9075

Mail Order Form

Request for Medicare Prescription Drug Coverage Determination

Request a coverage determination, including a request for tiering or formulary exception.

Mail completed form to:

  • TEAMStar Medicare Part D Prescription Drug Program (PDP)
  • P.O. Box 8080
  • McKinney, TX 75070
Medicare Prescription Drug Coverage Determination Request Form

Direct Member Reimbursement Form

Download this form to request reimbursement for a covered prescription drug you purchased at retail cost.

Mail completed form to:

  • OptumRx
  • P.O. Box 29046
  • Hot Springs, AR 71903

Direct Member Reimbursement Form

Hospice Status Form and Instructions

Use this form to communicate members’ Hospice status and unrelated medication overrides.

Fax to the number listed on the form.

Hospice Status and Plan of Care Form

Appointing a Representative Form

Download this form to appoint someone to act on your behalf when requesting a coverage determination. You can name a relative, friend, advocate, doctor, or anyone else to act for you. Some other persons may already be authorized under state law to act for you. If you want someone to act for you, then you and that person must sign and date this form.

Mail completed form to:

  • TEAMStar Medicare Part D Prescription Drug Program (PDP)
  • P.O. Box 8080
  • McKinney, TX 75070

Appointing a Representative Form

Downloadable Enrollment Form

Download an enrollment form that can be filled out by hand and mailed in to our offices.

TEAMStar Enrollment Form

Note: You must have Adobe Reader version 5.0 or higher installed on your computer in order to view and print the above file properly.

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Enroll Now

Enrolling online is the fastest and easiest way to get into the TEAMStar Medicare Part D Plan of your choice. Click the 'Enroll' button below to get started!

Contact Us

Contact Us

For your Medicare Part D questions and needs, please let us know how we can assist you.

Formulary.aspx

Drug Lookup and Pricing

Search for drugs covered on our Formulary and find out your costs.