Medicare Open Enrollment - Pharmacy Benefit Plans - Express Scripts 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the MEMBER INFORMATION section. Enter your member ID number, name, address, phone number, and birth date accurately.
3. In the RECIPIENT INFORMATION section, specify who can receive your information by providing their name, address, and relationship to you.
4. For the PURPOSE OF THE AUTHORIZATION, indicate why you are requesting this information to be shared. You can select 'At my request' or specify another purpose.
5. In the INFORMATION TO BE DISCLOSED section, choose whether to authorize all clinical and claims information or specify particular details. If sensitive information is included, initial where indicated.
6. Set the TERM OF AUTHORIZATION by specifying an end date or event for when this authorization should cease.
7. Review the CONDITIONS OF AUTHORIZATION carefully to understand how your information may be used after disclosure.
8. Finally, ensure that you or your personal representative signs and dates the form in the SIGNATURE REQUIRED section before submitting it.

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