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  • Diaper Request Form

  • TennCare and CoverKids allows up to 100 diapers per 30 days (or 200 diapers per 60 days) for members UNDER 2 years of age. Please complete ONE form per member.

  • Section A: Member's Information

  • Complete the entire section. For newborns who have not received their Optum Rx ID, please complete Section B as well.
  • Date of Birth:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Relationship to Member:

  • Section B: Mother's Information

  • Only complete for Newborns without an Optum Rx ID.
  • Date of Birth:
     - -
    2 digit month, 2 digit day, 4 digit year

  • Section C: Product Request

  • Members are not guaranteed the requested product. The pharmacy will fill with the closest item in stock, based on options covered by your plan.
  • Requested product type:

  • Section D: Attestation

  • Signature required.
  • I have requested the pharmacy to provide the above listed diapers/training pants and attest to the following:
    • The diapers/training pants requested above are for personal use for the indicated member.
    • I agree not to resale the diapers/training pants provided under this covered benefit.
    • I agree that once the pharmacy dispenses these diapers to me, they are no longer eligible for return or exchange at this pharmacy or at any other retailer.
    • I understand that a change in diaper style or size cannot be requested until the next refill.
    • I understand that this covered benefit is a diaper supplement and not intended to provide all the diapers member will require.
  • Today's date:
     - -
    2 digit month, 2 digit day, 4 digit year

  • For Pharmacy Use Only:

  • Request Method:
  • Date of Service
     - -
    2 digit month, 2 digit day, 4 digit year
  • Sig: Change diaper as needed when wet or soiled. Your plan covers 3.33 diapers per day. BIN: 001553 PCN: TNM (TennCare) or CKDS (CoverKids) Group: n/a
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  • Should be Empty: