Access common forms that members need from this central location. If you are looking for another form, please contact Member Services toll-free at 1.888.324.2064, Mon-Fri, 7 a.m. to 6 p.m. Central time.
Authorization to Disclose Protected Member Health Information
Medical Change Form (for updates to Individual policies including additions, deletions and address changes)
Member Submitted Claim Form
Preventive Care Guidelines
Search Medical Policies/Coverage Criteria
Use Preventive Guidelines Search Tool
Prescription Drug Reimbursement Form
Prior Authorization/Exception Form
2015 Diabetes Supplies List
2015 Growth Hormone List
Growth Hormone Statement of Medical Necessity Form
2015 Specialty Drug List
2015 High-Cost Drug List
myMailRx Order Form
myMailRx Over-the-Counter Order Form
myMailRx FAQ
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