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 Form
Your Right to Decide: Communicating Your Healthcare Choices Brochure
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Coordination of Benefits Form
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Preferred, Standard and Premium Drug List
Prior Authorization, Step-Edit and Quantity Limits Drug List
Generics Plus Formulary
Optima Health Injectable & Infusion Medication List
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Confidentiality Agreement Form
Portal User Profile Form
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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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COBRA ARRA Form
This form is to be completed and submitted for all employees who are eligible for ARRA premium subsidies, regardless of employer size.
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Instructions for Mail Order Pharmacy
Caremark Mail Service Form
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Instructions for Pharmacy Reimbursment
Direct Member Reimbursement Form
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Release of Information (ROI)
Release of Information Form
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Student Verification Form
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Transitional Care Request Form
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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
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