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Forms 2024

Click here to 2025 Forms

  • Coverage Determination

    Coverage Determination

    Use it to request that we cover a prescription not currently included in the plan in which a member is enrolled. A doctor typically fills this out for the member

    Download
  • Appointment of Representative

    Appointment of Representative

    Used to appoint any individual, including an attorney, to represent a member during the processing of a claim or claims, and/or any subsequent appeal or in connection with any aspect of dealing with an insurance provider.

    Download
    *See below for instructions on how to appoint a representative
  • Member Grievance and Appeal

    Member Grievance and Appeal

    To file an appeal (request for us to consider our decision) or a grievance about any service received from one of our network providers.

    Download
  • Prescription Reimbursement

    Prescription Reimbursement

    *Use it to request reimbursement for covered medications purchased at retail cost. Complete one form per member.

    Download
    *OptumRx Form
  • Mail Order

    Mail Order

    *Use it to place your order for prescription drugs through the mail. You may find using a mail-order pharmacy to be a cost effective and convenient way to fill prescriptions for drugs you take every day.

    Download
    *OptumRx Form
  • Medical Reimbursement Request Form

    Medical Reimbursement Request Form

    Use it to request a reimbursement for in-country and foreign covered medical expenses. Additional paperwork may be required. (Examples. Receipts, itemized invoices/bills and others.) Please contact Costumer Service for more information.

    Download

*Appoint a representative


You can ask someone to act on your behalf. If you want to, you can name another person to act for you as your “representative” to ask for a coverage decision or make an appeal.


  • There may be someone who is already legally authorized to act as your representative under State law.
  • If you want a friend, relative, your doctor or other provider, or other person to be your representative, fill out the form to give that person permission to act on your behalf. The form must be signed by you and by the person who you would like to act on your behalf. You must mail the signed form to the Member Services Department