forms

Prescription Claim Form

Complete the claim form
 and submit it to:

 

EnvisionRx Options, Inc.

2181 East Aurora Road, Suite 201

Twinsburg, Ohio 44087

 

Mail Order Form

Costco Mail Order Pharmacy

215 Deininger Circle

Corona, CA  92880-9911

 

Envision, Letter of Medical Necessity

 

Envision, Step Therapy Exception Form

Medical Claim Form

For reimbursement, complete items
1-9 of the claim form,
attach receipt(s) and submit to:


Tri-County Schools Insurance Group

c/o Delta Health Systems

P. O. Box 80

Stockton, CA 95201-3080

 

If you need Delta Health Systems to reimburse the provider,
then also sign item 10 and following the same procedures
listed above.

 

One claim form per patient.

 

1176 LIVE OAK BOULEVARD, SUITE A | YUBA CITY, CA 95991 | 866-822-5299

© TRI-COUNTY SCHOOLS INSURANCE GROUP