Summaries & Forms

General Forms

This document describes what the plan covers and what it costs.

Glossary of Health Coverage and Medical Terms

This is a detailed outline of your health care coverage

Protected Health Information Authorization

Use this form to let us know if you want to allow someone other than yourself to discuss your health information. This could be your wife or husband, a relative, an attorney and so on.

Preventive Care

This link reviews the preventive care expenses covered under Health Care Reform.

Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed and how you can get access to this information.

Qualified Medical Child Support Order

This document contains information regarding medical child support orders.

Other Health/Dental Coverage Questionnaire

To provide information about possible other coverage.

Health Benefits Claim Form

Use this form for filing claims incurred from a non-network provider.

Prescription Drug Forms

Preferred Drug List (PDL)

With our PDL, you and your doctor have the freedom to choose the medication that works best for you.

Caremark National Pharmacy Network

List of participating chain and independent retail pharmacies.

Rx Quantity Limit Program Handout

Explains Rx Quantity Management program and lists appropriate prescription drugs.

Rx Prior Authorization List

Explains Rx Prior Authorization program and lists appropriate prescription drugs

Step Therapy Handout

Explains Rx Step Therapy program and lists appropriate prescription drugs

Specialty Drug Flyer

Lists and explains how certain specialty drugs are covered.

CareMark Mail Service Order Form

Use this form to process prescription drug orders under the mail service plan.

CareMark Paper Claim Form

Use this form to obtain reimbursement for a prescription drug.

Excluded Drug List

These drugs are excluded from coverage as of the date of this list.

Self Funded Forms

Self Funded EOB Guide

Use this form as a guide to read your Explanation of Benefits for claims.

Self Funded Accident Form

Use this form to let us know if health care was the result of an accident.

Self Funded Subrogation Form

Use this form to let us know if you will be getting a settlement payment for an accident from another person or business. This form lets us know that we will be reimbursed for any treatment we have paid for due to that accident.

Self Funded Yearly Claim Form

Use this form to let us know if there have been any changes that would affect your insurance, such as a spouse getting or losing coverage under other insurance, or if a child has become or is no longer a full time student.

Claims Transmittal Form

Use this form to file a claim with medical bills and Prescription Drug receipts.

Miscellaneous Forms & Documents

Definitions

Reasons Medical Claims Denied

This document explains the top reasons why a medical claim could be denied.

Medicaid/Chip Notice

Medicaid and the Children’s Health Insurance Program (CHIP) offer free or low-cost health coverage to children and families.

24 Hour Nurse Advisor

Information about this free service from your employer.