Forms and Documents

 

 Advance Directive

 Out-of-Area Dependent

 Broker Guides

 Pharmacy Mail Order

 Coordination of Benefits

 Pharmacy Reimbursement

 Drug Lists

 Release of Information (ROI)

 HIPAA Agreement for PHI

 Student Verification

 Member Appeals

 Transitional Care

 

 

Some of our most-requested forms are available for you to view and print online.  Our downloadable forms require Adobe Reader in order to view and print -- get Adobe Reader.

Advance Directive

What is an Advance Directive?

 

Advance Directive Form

 

Your Right to Decide: Communicating Your Healthcare Choices Brochure

 

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Broker Guides

Broker Guide

 

Individual and Family Health Plans Broker Guide

 

Individual and Family Health Plans Broker Website Guide

 

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Coordination of Benefits

Coordination of Benefits Form

 

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Drug Lists

Download Preferred, Standard and Premium Drug List

 

Prior Authorization, Step-Edit and Quantity Limits Drug List

 

Generics Plus Formulary (includes Individual and Family Health Plans)

 

Medication Transition of Care Form

 

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HIPAA Agreement for Personal Health Information (PHI)

HIPAA Agreement

 

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Member Appeals

Member Appeals Packet

 

Member Complaints Packet

 

Member Complaints Packet (Family Care Members)

 

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Out-of-Area Dependent 

 

Out-of-Area Dependent Form

 

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Pharmacy Mail Order

Instructions for Mail Order Pharmacy


Caremark Mail Service Form

 

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Pharmacy Reimbursement

Instructions for Pharmacy Reimbursment


Direct Member Reimbursement Form

 

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Release of Information (ROI)

Designated Agent Form (formerly called ROI)

 

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Student Verification

Student Verification Form

 

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Transitional Care 

Transitional Care Request Form 

 

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Last Updated January 02, 2009 9:46:39 AM