Forms Library
Internal Appeal Request Form
Allows you to ask your health plan to review and reconsider a denied claim or coverage decision.
Internal Appeal Request Form - Second Level
Request a higher-level review after an initial appeal isn’t approved.
FSA HC Reimbursement Request
Submit eligible healthcare expenses for reimbursement from your FSA.
FSA Dependent Care Reimbursement Request Form
Submit eligible dependent care expenses for reimbursement from your FSA.
Health Reimbursement Account (HRA) Rx Form
Submit prescription receipts for payment or reimbursement from your HRA.
Health Reimbursement Account (HRA) Group Form
Submit eligible healthcare expenses for reimbursement from your group HRA.
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.
Medical Exception Request Form - Non-Formulary
Request coverage for a medication that isn’t on your plan’s approved drug list.
Medical Exception Request Form - Tiering Exception
Request a lower copay tier for a covered medication when medically necessary.
Quantity Limit Medical Necessity Request Form
Request approval for a higher amount of medication than your plan normally covers.
Quantity Limit Medical Necessity – Proton Pump Inhibitors
Request a higher quantity for a PPI medication due to medical necessity.
Step Therapy Medication Medical Necessity Form
Request to bypass step-therapy requirements due to medical necessity.
Covered Persons Rights & Responsibilities
Overview of your rights and responsibilities as a plan member.
Mail Order Prescription Reimbursement Form
Submit for reimbursement if you purchase your medications outside the plan’s mail-order pharmacy.
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