Forms Library
Rx Reimbursement Form
Allows you to submit receipts for prescriptions you paid for yourself so you can be reimbursed by your pharmacy benefit plan.
DownloadMedical 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.
DownloadInternal Appeal Request Form
Allows you to ask your health plan to review and reconsider a denied claim or coverage decision.
DownloadHIPAA 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.
DownloadMedical Exception Request Form - Tiering Exception
Request a lower copay tier for a covered medication when medically necessary.
DownloadHealth Reimbursement Account (HRA) Rx Form
Submit prescription receipts for payment or reimbursement from your HRA.
DownloadQuantity Limit Medical Necessity Request Form
Request approval for a higher amount of medication than your plan normally covers.
DownloadMedical Exception Request Form - Non-Formulary
Request coverage for a medication that isn’t on your plan’s approved drug list.
DownloadHealth Reimbursement Account (HRA) Rx Form
Submit prescription drug expenses to be reimbursed from your HRA.
DownloadQuantity Limit Medical Necessity Request Form
Request approval for a higher quantity of a medication than normally allowed.
DownloadFSA HC Reimbursement Request
Submit eligible healthcare expenses for reimbursement from your FSA.
DownloadHIPAA Authorization to Use and/or Disclose PHI
Give permission for your PHI to be shared with specific parties.
DownloadClinical Medical Release Form
Authorize your provider to share medical records with your health plan or others.
DownloadInternal Appeal Request Form - Second Level
Request a higher-level review after an initial appeal isn’t approved.
DownloadHIPAA Request for Access to Designated Record Set
Request access to view or obtain copies of your health information.
DownloadFSA Dependent Care Reimbursement Request Form
Submit eligible dependent care expenses for reimbursement from your FSA.
DownloadAuto-PIP Request for Medical Necessity Form
Request coverage for medical treatments under Personal Injury Protection (PIP).
DownloadHIPAA Authorization for Disclosure of PHI
Give permission for your health information to be shared.
DownloadMedical Exception Request Form – PCRx Cost Exceeds
Request coverage when medication cost exceeds the plan’s usual limit.
DownloadWorkers’ Compensation Request for Medical Necessity Form
Request approval for medical services under workers’ compensation.
DownloadHealth Reimbursement Account (HRA) Group Form
Submit eligible healthcare expenses for reimbursement from your group HRA.
DownloadHIPAA Request for Restriction of PHI Form
Ask your health plan/provider to limit how your PHI is used or shared.
DownloadHIPAA Revocation of Authorization to Use and/or Disclose PHI Form
Cancel a previous authorization to disclose your PHI.
DownloadStep Therapy Medication Medical Necessity Form
Request to bypass step-therapy requirements due to medical necessity.
DownloadQuantity Limit Medical Necessity – Proton Pump Inhibitors
Request a higher quantity for a PPI medication due to medical necessity.
DownloadCovered Persons Rights & Responsibilities
Overview of your rights and responsibilities as a plan member.
DownloadStill have a question?
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