365 days from the date the prescription is filled. For questions about the filing period,please call the number on the back of your member ID card; 2. If submitting a request where medications were obtained from multiple pharmacies or physicians or a request is for multiple members, please submit a separate form for each pharmacy or physician and member. Member ID number (required): Date of Birth (mm/dd/yyyy): Member name (Last, First, MI): Street address: Phone number: City: Gender: State.

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