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
to top
Claims
Instructions on How to File a Claim
Out-of-Network Vision Claim Form
Out-of-Network Chiropractic Claim Form (for members with chiropractic benefits only)
Out-of-Area Dependent Notification Form (for members whose employer has purchased the Out-Of-Area dependent rider)
Patient's Request for Medical Payment Form (Medicare)
to top
Coordination of Benefits
Coordination of Benefits Form
to top
Complaints and Member Appeals
Resolving Complaints and Appeals
Member Appeals Packet
Member Complaints Packet
Member Complaints Packet (Family Care Members)
Optima Medicare (PPO): Grievance, Coverage Determination and Appeals Process for Parts C and D
to top
Drug Lists
Preferred, Standard and Premium Drug List
Prior Authorization, Step-Edit and Quantity Limits Drug List Pharmacy packaging limits have been removed from most drugs, allowing you to get a full month supply for a single copay View the list above for drugs that continue to have a quantity limit.
Generics Plus Formulary
Medicare Drug Authorization Forms
Exception Form
2010 Optima Medicare (PPO) Drug List
2009 Optima Medicare (PPO) Drug List
Optima Health Injectable & Infusion Medication List
to top
Pharmacy Mail Order
Instructions for Mail Order Pharmacy
Caremark Mail Service Form
CVS Caremark MEDICARE Part D Confidential Mail Service Enrollment Form
to top
Pharmacy Reimbursement
Instructions for Pharmacy Reimbursement
Direct Member Reimbursement Form
to top
Pre-Existing Condition Letter
Pre-Existing Condition Letter
to top
Authorizations for Release of Medical Information
Designated Agent Form - Health Equity
Authorization for Use or Disclosure of Medical Information
What is the Authorization for Use or Disclosure of Information
Designated Representative Authorization Form
Designated Agent Form
to top
Student Verification
Student Verification Form
Out-of-Area Student Verification Form (for members whose employer has purchased the Out-Of-Area dependent rider)
to top
Transitional Care
Transitional Care Request Form
to top