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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
 
Published on January 07, 2019