HometownRx Large and Small Group Medication Request Form
This form is to be used by participating physicians and providers to obtain coverage for a formulary drug requiring prior authorization (PA), a non-formulary drug for which there is no suitable alternative available, or any overrides of pharmacy management procedures such as step therapy, quantity limit, or other edits.

HometownRx Individual and Family Medication Request Form
This form is to be used by participating physicians and providers to obtain coverage for a formulary drug requiring prior authorization (PA), a non-formulary drug for which there is no suitable alternative available, or any overrides of pharmacy management procedures such as step therapy, quantity limit, or other edits.

HometownRx Large and Small Group Prescription Drug Claim Form
HometownRx makes reimbursement decisions based on the contract we have with the pharmacy where your medication was purchased. Therefore, we will only reimburse up to the amount that HometownRx would have paid if the prescription drug was purchased using your insurance policy. Our contracted amount could be less than the amount you were charged. Reimbursement decisions are also made based on your insurance policy co-pay or coinsurance.

HometownRx Individual & Family Prescription Drug Claim Form
HometownRx makes reimbursement decisions based on the contract we have with the pharmacy where your medication was purchased. Therefore, we will only reimburse up to the amount that HometownRx would have paid if the prescription drug was purchased using your insurance policy. Our contracted amount could be less than the amount you were charged. Reimbursement decisions are also made based on your insurance policy co-pay or coinsurance.

Oncology Step Therapy Exemption Form
This form is to be used by participating physicians and providers to request a step therapy exemption for patients who have been diagnosed with stage three or four cancer.