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Claim Forms
Type of Expense
Form Name
Purpose
Health Care
Extended Health Care and Health Spending Account Claim Form
Use this form when you want to submit a health care claim under your Health Care Plan or Health Spending Account
Dental Care
Dental and Health Spending Account Claim Form
Use this form when you want to submit a dental claim under your Dental Care Plan or Health Spending Account
Prior Approval Forms
Type of Form
Form Name
Purpose
Brand Name Exception
Drug Exception Application Form
Use this form when you want to request approval for coverage
Enhanced Prior Authorization
Prior Authorization Form
Use this form to request prior approval for coverage under the program for Specialty Drugs
Preauthorized Weight Loss Drug
Preauthorized Weight Loss Drug Approval Form
Use this form to request approval for coverage under the program for Weight Loss Drugs
Disabled Child
Disabled Child Approval Form
Use this form to request continuation of coverage for your
child, who depends on you for support because of a psychiatric or physical disability and became disabled before age 21
Application and Beneficiary Forms
Type of Plan
Form Name
Purpose
Basic Life Insurance Plan - Beneficiary Designation
Basic Life Insurance Plan Naming or Substitution of Beneficiary
Use this form to nominate or change a beneficiary for your Life Insurance benefits
Business Travel AD&D - Beneficiary Designation
Business Travel AD&D Naming or Substitution of Beneficiary
Use this form to nominate or change a beneficiary for your Business Travel AD&D benefits
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Published on January 07, 2019
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