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Access Important Forms

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.

Pharmacy Preauthorization Form: Antidepressants

Who Needs This Form?

If you are a ConnectiCare member

When To Use It

If you are seeking to obtain authorization for antidepressant medications.

Instructions/Notes

  • 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.

Pharmacy Preauthorization Form: ARB's

Who Needs This Form?

If you are a ConnectiCare member

When To Use It

If you are seeking to obtain authorization for Angiotensin II Receptor Blockers.

Instructions/Notes

  • Print the form.

  • Fill in the appropriate information.

  • Fax the completed form to Pharmacy Services (860) 647-2851 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.

Pharmacy Preauthorization Form: Cimzia

Who Needs This Form?

If you are a ConnectiCare member

When To Use It

If you are seeking to obtain authorization for Cimzia.

Instructions/Notes

  • 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.

Pharmacy Preauthorization Form: Hepatitis C

Who Needs This Form?

If you are a ConnectiCare member

When To Use It

If you are seeking to obtain authorization for interferon treatment of Hepatitis C.

Instructions/Notes

  • 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, 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.

Pharmacy Preauthorization Form: Hyaluronic Acid Derivatives

Who Needs This Form?

If you are a ConnectiCare member

When To Use It

If you are seeking to obtain authorization for injectable Hyaluronic Acid products (i.e. Synvisc).

Instructions/Notes

  • Print the form.

  • Fill in the appropriate information.

  • Fax the completed form to Pharmacy Services (860) 647-2851 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.

Pharmacy Preauthorization Form: Immunomodulators

Who Needs This Form?

If you are a ConnectiCare member

When To Use It

If you are seeking to obtain authorization for immunomodulating treatment.

Instructions/Notes

  • Print the form.

  • Fill in the appropriate information.

  • Fax the completed form to Pharmacy Services (860) 647-2851 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.

Pharmacy Preauthorization Form: Infertility Therapy

Who Needs This Form?

If you are a ConnectiCare member

When To Use It

If you are seeking to obtain authorization for infertility therapy, including infertility prescription drug requests.

Instructions/Notes

  • 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.

Pharmacy Preauthorization Form: Massachusetts Provider Form

Who Needs This Form?

If you are a ConnectiCare member

When To Use It

If you are seeking to obtain authorization within Massachusetts.

Instructions/Notes

  • Print the form.

  • Fill in the appropriate information.

  • Fax the completed form to Pharmacy Services (860) 647-2851 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.

Pharmacy Preauthorization Form: Migraine Medication

Who Needs This Form?

If you are a ConnectiCare member

When To Use It

If you are seeking to obtain authorization for migraine medications.

Instructions/Notes

  • Print the form.

  • Fill in the appropriate information.

  • Fax the completed form to Pharmacy Services (860) 647-2851 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.

Pharmacy Preauthorization Form: Physician Administered Drugs

Who Needs This Form?

If you are a ConnectiCare member

When To Use It

If you are seeking to obtain authorization for a physician administered drugs (e.g., injectable drugs).

Instructions/Notes

  • Print 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.

Pharmacy Preauthorization Form: Proton Pump Inhibitor

Who Needs This Form?

If you are a ConnectiCare member

When To Use It

If you are seeking to obtain authorization for a Proton Pump Inhibitor.

Instructions/Notes

  • 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.

Pharmacy Preauthorization Form: Sedatives/Hypnotics

Who Needs This Form?

If you are a ConnectiCare member

When To Use It

If you are seeking to obtain authorization for sedative hypnotics.

Instructions/Notes

  • Print the form.

  • Fill in the appropriate information.

  • Fax the completed form to Pharmacy Services (860) 647-2851 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.

Pharmacy Preauthorization Form: Statin Medications

Who Needs This Form?

If you are a ConnectiCare member

When To Use It

If you are seeking to obtain authorization for a statin cholesterol lowering medication requiring preauthorization.

Instructions/Notes

  • 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.


Pharmacy Preauthorization Form: Crohn and Psoriasis Medications

Who Needs This Form?

If you are a ConnectiCare member

When To Use It

If you are seeking to obtain authorization for crohn's disease or psoriasis medications.

Instructions/Notes

  • 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.

Pharmacy Preauthorization Form: Testosterone Replacement

Who Needs This Form?

If you are a ConnectiCare member

When To Use It

If you are seeking to obtain authorization for testosterone replacement therapy.

Instructions/Notes

  • Print the form.

  • Fill in the appropriate information.

  • 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.

Pharmacy Preauthorization Request Form: General Requests

Who Needs This Form?

If you are a ConnectiCare member

When To Use It

If you are seeking to obtain authorization for medications other than certain specific drugs that require their own form, as listed above.

Instructions/Notes

  • 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.

Prescription Drug Reimbursement Claim Form

Who Needs This Form?

If you are a ConnectiCare member

When To Use It

If you are seeking to receive reimbursement for prescriptions that were purchased without the use of your ConnectiCare ID Card.

Instructions/Notes

  • 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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