Plan design brochures
Guides
- Member Rights and Responsibilities
- Preventive Services Guide (2023)
- Prior Authorization Quick Guide (2023)
- Understanding Your EOB (Explanation of Benefits)
Pharmacy
- Non-Formulary Medications
- Prescription Medication List (2023)
- Pharmacy Direct Reimbursement Claim Form
- Pharmacy Mail Order Request Form
- Pharmacy Prior Authorization Forms
Member newsletter
Member forms
- At Home Covid-19 Test Reimbursement Form
- Authorization for Disclosure
- Automatic Payment Election Form
- Coordination of Benefits Verification Form
- Enrollment Application for Individual or Family
- Member Request for Accounting of Disclosures of Protected Health Information (PHI)
- Out-of-Network Claim Form
- Off-Exchange Policy Cancellation Form
- PHI Release
- Form Tobacco Use Affidavit