Member Forms & Resources
Electronic Funds Transfer (EFT) Form
- Use this authorization agreement form for ACH debit to allow your plan to withdraw your monthly plan premium payment from your checking or savings account on the 10th of each month.
Medicare Member Designated Representative Form
- Complete this form if you want someone to act on your behalf. To prevent unauthorized use, these forms are posted on our Secure Member Portal.
Prescription Drug Forms
- Locate prescription drug forms including mail order and reimbursement forms.
Member Medical Reimbursement Form
- Return the completed form and applicable receipts to the address for your health plan listed in the attached document.
Part D Vaccine & Administration (Injection) Claim Form
- This claim form is for reimbursement of covered Part D vaccines and their administration (injection). Please consult your Evidence of Coverage for specific coverage information.
Prescription Drug Claim Form
- Request reimbursement for prescription drugs by completing this form.
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