AlaskaCare Retiree Forms

Pharmacy Forms

Mail Order Pharmacy form

Costco Pharmacy Mail Order form [PDF 102K]

Submit this form to send prescriptions and payment and reorder

Mail Order Profile form

Costco Pharmacy Traditional Mail Order Service Patient Profile form [PDF]

Please complete, sign, and return this form only if this is your first time using our mail order pharmacy.

Prescription Drug Self-Pay Reimbursement form

Prescription Drug (member self-pay) Reimbursement form [PDF 249K]

Submit this form for your prescription benefit program member self-payment reimbursement