| 1-866-231-7201 (TTY - 711) Toll-Free |
|---|
| 8 a.m. - 8 p.m. local time, 7 days a week |
| Form Name | Description |
|---|---|
|
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.
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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.
|
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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.
|
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Prescription Reimbursement
|
**Use it to request reimbursement for covered medications
purchased at retail cost. Complete one form per member.
|
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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.
|
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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.
|
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.
