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Forms for prescriptions

Most of the forms below are PDF files. If you encounter any problems viewing PDFs on your computer, you may need to install the free Adobe Reader software.

PLEASE NOTE: The “Application For Age 26 Young Adult Coverage” form is no longer required by the UFT Welfare Fund. Members wishing to add a dependent under age 26 to their Welfare Fund coverage at no cost should use the Welfare Fund’s online Update Your Information (Change of Status) form.

  • Drug Reimbursement Form for In-Service Members

    Include all original pharmacy receipts with prescription detail clearly noted which must include the name, strength, quantity and price. Please attach to this form. Receipts must be mailed within 90 days from date of service. Reimbursement will be in accordance with a Schedule of Allowances.

  • Express Scripts Preferred Formulary

    The following is a list of the most commonly prescribed drugs. It represents an abbreviated version of the drug list (formulary) that is at the core of our prescription drug benefit.

  • Mandatory Generic Price Waiver Form

    This price waiver form must be completed by both the member and his/her physician in cases where a brand rather than generic prescription is deemed medically necessary.

  • Medicare Part D Creditable Coverage Disclosure Notice

    For members: this notice has information about your current prescription drug coverage with the UFT Welfare Fund and your options under Medicare’s prescription drug coverage. Please read carefully.

  • Medicare Part D Reimbursement Claim Form

    This is your Medicare Part D Reimbursement Claim Form, for retired members and their spouses/domestic partners.