Forms Library

Reimbursement

Rx Reimbursement Form

Allows you to submit receipts for prescriptions you paid for yourself so you can be reimbursed by your pharmacy benefit plan.

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Medical Exception

Medical Exception Request Form

Used when your doctor requests coverage for a medication that isn’t normally covered by your plan because it’s needed for your specific medical situation.

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Appeals

Internal Appeal Request Form

Allows you to ask your health plan to review and reconsider a denied claim or coverage decision.

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HIPAA

HIPAA Request for Accounting of Disclosures of PHI

Lets you request a record of when and why your health information has been shared by your health plan.

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Medical Exception

Medical Exception Request Form - Tiering Exception

Request a lower copay tier for a covered medication when medically necessary.

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HRA

Health Reimbursement Account (HRA) Rx Form

Submit prescription receipts for payment or reimbursement from your HRA.

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Medical Exception

Quantity Limit Medical Necessity Request Form

Request approval for a higher amount of medication than your plan normally covers.

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Medical Exception

Medical Exception Request Form - Non-Formulary

Request coverage for a medication that isn’t on your plan’s approved drug list.

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HRA

Health Reimbursement Account (HRA) Rx Form

Submit prescription drug expenses to be reimbursed from your HRA.

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Medical Exception

Quantity Limit Medical Necessity Request Form

Request approval for a higher quantity of a medication than normally allowed.

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FSA

FSA HC Reimbursement Request

Submit eligible healthcare expenses for reimbursement from your FSA.

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HIPAA

HIPAA Authorization to Use and/or Disclose PHI

Give permission for your PHI to be shared with specific parties.

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HIPAA

Clinical Medical Release Form

Authorize your provider to share medical records with your health plan or others.

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Appeals

Internal Appeal Request Form - Second Level

Request a higher-level review after an initial appeal isn’t approved.

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HIPAA

HIPAA Request for Access to Designated Record Set

Request access to view or obtain copies of your health information.

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FSA

FSA Dependent Care Reimbursement Request Form

Submit eligible dependent care expenses for reimbursement from your FSA.

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Claims

Auto-PIP Request for Medical Necessity Form

Request coverage for medical treatments under Personal Injury Protection (PIP).

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HIPAA

HIPAA Authorization for Disclosure of PHI

Give permission for your health information to be shared.

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Medical Exception

Medical Exception Request Form – PCRx Cost Exceeds

Request coverage when medication cost exceeds the plan’s usual limit.

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Claims

Workers’ Compensation Request for Medical Necessity Form

Request approval for medical services under workers’ compensation.

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HRA

Health Reimbursement Account (HRA) Group Form

Submit eligible healthcare expenses for reimbursement from your group HRA.

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HIPAA

HIPAA Request for Restriction of PHI Form

Ask your health plan/provider to limit how your PHI is used or shared.

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HIPAA

HIPAA Revocation of Authorization to Use and/or Disclose PHI Form

Cancel a previous authorization to disclose your PHI.

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Medical Exception

Step Therapy Medication Medical Necessity Form

Request to bypass step-therapy requirements due to medical necessity.

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Medical Exception

Quantity Limit Medical Necessity – Proton Pump Inhibitors

Request a higher quantity for a PPI medication due to medical necessity.

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Other

Covered Persons Rights & Responsibilities

Overview of your rights and responsibilities as a plan member.

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