Forms & publications

Members can use this form when purchasing specialty drugs through Ardon Health to request that Ardon Health not use child-resistant caps ("safety caps") to package a member's medication. Ardon Health is a member of Washington State Rx Services (WSRxS)

Ardon Health Protected health information (PHI) disclosure authorization form. Ardon Health is a member of Washington State Rx Services (WSRxS).

This is a form that members must complete and send with initial order for specialty drugs from the Uniform Medical Plan (UMP) network specialty pharmacy, Ardon Health. Ardon Health is a member of Washington State Rx Services (WSRxS).

This document contains information about prescription drugs covered under the UMP Classic Medicare with Part D (PDP) plan.

This form directs ArrayRx to communicate with you about your personal health information at the address you select. This form does not apply to your health care provider. You must give your provider separate, specific instruction about what health information they may share and with whom.

This documents provides a list of UMP Classic Medicare with Part D (PDP) network pharmacies. This directory is for network pharmacies in Washington State and Oregon. ArrayRx does cover a service larger area and more network pharmacies may be available to members upon request.

This form is for UMP Classic Medicare with Part D (PDP) members to use when authorizing a representative to act on your behalf.

This form is used as a request for Medicare prescription drug coverage. ArrayRx administers all prescription drug coverage for UMP Medicare members.

This form is used for appeals when UMP Medicare members have been denied prescription drug coverage. ArrayRx administers all prescription drug benefits for UMP Medicare members.

This form is for notifying ArrayRx that you have prescription drug coverage in addition to Uniform Medical Plan (UMP).