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This page contains forms pertaining to the prescription benefits available through the University of Kentucky health plans.

Prescription

Form Description
Mail order form – active employees and under 65 retirees
Mail order form – Medicare retirees
Manual claim form for employees and retirees under age 65

Under some circumstances it may be necessary to manually file a prescription claim.  For example if you are out of town and cannot locate your Express Scripts ID card, it may be necessary to pay for the prescription and manually file for reimbursement once you return. 

Please note claims must be filed within twelve (12) months of receiving a prescription.

Manual claim form for retirees age 65 and over (Medicare Advantage Plan)

Under some circumstances it may be necessary to manually file a prescription claim.  For example if you are out of town and cannot locate your Express Scripts ID card, it may be necessary to pay for the prescription and manually file for reimbursement once you return. 

Please note claims must be filed within twelve (12) months of receiving a prescription.

Medicare Rx EOC 2021
Medicare Rx EOC 2022
Prescription formulary 2021-2022 (active employees and under 65 retirees)

Prescription formularies for UK health plan members on either HMO, PPO, RHP, EPO, Saver or Indemnity plans.

If you have any questions, call our pharmacists with the Know Your Rx Coalition at (859) 218-5979 or (855) 218-5979 for information specific to your medication, formulary and costs.

Saveon SP Non-Essential Coverage Specialty Drug List
UK Medicare Part D Prescription Formulary 2021
UK Medicare Part D Prescription Formulary 2022