Member Service

Formulary Drug Listing:

Prior Authorization Drug Listing:

Specific Drug Listings for California group contracts:

• Drug List/Formulary - 9/1/20

Specific Drug Listings for Illinois group contracts:

Specific Drug Listings for New York group contracts:

Specific Drug Listings for Texas group contracts:

• Prior Authorization Request Form for Prescription Drug Benefits - TX

• California
• Colorado
• Connecticut
• Georgia
• Illinois
• Indiana
• Kentucky
• Michigan
• New Jersey
• New York
• Ohio
• Pennsylvania
• South Carolina
• Tennessee
• Texas
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• Oregon

• Claim Payment Overview

• Prior Authorization/Precertification

• Claim forms: Looking for a claim form? You may print or download one of the following forms to use.
  
  Standard Claim Forms
  Medical
  
  • Medical Claim Form
  • Medical Claim Form - CA
  • Member or Members Dependent Authorization for Disclosure of Health Information
  
  Dental
  • Dental Claim Form
  • Dental Claim Form - CA
  • Dental Claim Form - NJ
  • Member or Members Dependent Authorization for Disclosure of Health Information
  
  Forms
  • Vision Claim Form
  • Vision Claim Form - CA
  • EyeMed Vision Care Out of Network Claim Form
  • CVS Caremark Prescription Reimbursement Claim Form
  • FSA Request for Reimbursement Form
  • Limited Purpose FSA Claim Form
  • HRA Claim Form
  • Member or Members Dependent Authorization for Disclosure of Health Information
  
  Life
  • Life Insurance Claim Form
  • Life Insurance Beneficiary Quick Reference Guide
  • Life Insurance Beneficiary Designation/Change Form
  • Life Insurance Community Property Consent Form
  
  Disability
  • Disability Claim Form
  • Continuance of Disability Form

Want to look up the status of a claim? Or review your benefits? Register and log in to our member portal to have immediate access to all of the information you need about your insurance coverages.

• Affordable Care Act Questions and Answers