Member Materials
Plan design brochures
Guides
- Member Rights and Responsibilities
- Preventive Services Guide (2025)
- Prior Authorization Quick Guide (2025)
- Understanding Your Explanation of Benefits (EOB)
- Payment Terms to Know
Pharmacy
- Non-Formulary Medications
- Prescription Medication List
- Pharmacy Direct Reimbursement Claim Form
- Pharmacy Mail Order Request Form
- Pharmacy Prior Authorization Forms
Member forms
- Authorization for Disclosure
- Automatic Payment Election Form
- Coordination of Benefits Verification Form
- 2025 Enrollment Application for Individual or Family
- 2025 Dental Enrollment Application
- Member Request for Accounting of Disclosures of Protected Health Information (PHI)
- Out-of-Network Claim Form
- Off-Exchange Policy Cancellation Form
- PHI Release