Forms and Documents

 

 Advance Directive

 Pharmacy Mail Order

 Broker Guides

 Pharmacy Reimbursement

 Coordination of Benefits

 Release of Information (ROI)

 Drug Lists

 Student Verification

 HIPAA Agreement for PHI

 Transitional Care

 Member Appeals

 Enrollment Applications

 Out-of-Area Dependent

 The American Recovery and Reinvestment Act of 2009 (ARRA) Forms

 

 

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

 

Access the collection of Broker Guides

 

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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 (Utilization Management List)

 

Access Drug Authorization Forms

 

Generics Plus Formulary (includes Individual and Family Health Plans)

 

Optima Health Injectable & Infusion Medication List

 

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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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Enrollment Applications

 

Small Group Enrollment Applications

 

Small Group Member Enrollment Application

 

Virginia Small Employer Group Universal Enrollment Application

 

Large Group Enrollment Applications

 

Vantage Member Enrollment Application

 

Plus Member Enrollment Application

 

POS Member Enrollment Application

 

FourSight Member Enrollment Application

 

Equity Member Enrollment Application

 

Design Vantage Member Enrollment Application

 

Design POSA Member Enrollment Application

 

Design Plus Member Enrollment Application

 

Self Funded Member Enrollment Application

 

Health Savings Accounts (HSA) Enrollment Form

 

Optima Equity Health Savings Account (HSA) Enrollment Form

 

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The American Recovery and Reinvestment Act of 2009 (ARRA) Forms

 

Virginia Small Employer COBRA

 

COBRA 35% Letter

 

Optima Health ARRA Form (.xls)

 

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Last Updated March 12, 2010 2:58:30 PM