Coordination of Benefits (COB) Questionnaire Form

Notify the Plan of other insurance coverage in order to determine the order of benefits/coverage. You can also submit this form by logging in to your Benefits Manager  and selecting 'Forms.'

Accident Questionnaire Form

When you have a claim, if you get into an accident/injury, notify the Plan of the other party's coverage in order to determine the order of benefits/coverage. You can also submit this form by logging in to your Benefits Manager and selecting 'Forms.'

CVS Caremark Rx Claim Form

Get reimbursed for prescription drug claims. This includes submitting prescription receipts for secondary coverage to CVS Caremark.

Working Spouse Rule: Employer Declaration Form

Per the Plan’s Working Spouse Rule, your spouse will need to confirm whether they have access to and are enrolled in their employer's health plan. The Plan is partnering with Cotiviti (formerly HMS) to collect any details related to your family's other health coverage (if any). 

If your spouse is employed but does not have insurance coverage through their employer at this time, please have their employer complete this form. Once completed the form will be returned to Cotiviti per the instructions on the form. Please make sure to include the participant’s identifying information at the top of the form before sending to Cotiviti.

Medical Claim Form

Submit medical care claims to the Plan via our secure Benefits Manager portal through the Message Center with the "envelope" icon on the top right. Please be advised that no rights under the Plan, including but not limited to the right to receive any benefit or any right to pursue a Claim or cause of action, are assignable to another party. For more information see the "Authorized Representatives” section of the SPD.

Delta Dental Claim Form

Submit dental care claims if you are treated by a dentist who is not a member of Delta Dental. See instructions on how to submit this form.

Beacon Health Options Mental Health/Substance Abuse Treatment Claim Form

Submit this form for mental health/substance abuse treatment claims. You may also fill out and submit an online form on the Achieve Solutions website.

Health Insurance Claim Form

Health care providers can submit this form for services provided to patients.