Forms

  • DisposeRx® Request Form
    Get a free DisposeRx packet to help you dispose of unused or expired medications.
  • Fraud, Waste and Abuse Reporting Form
    Use this form if you think that a beneficiary, provider, or pharmacy is taking part in fraud, waste, abuse or overpayment.
  • Grievance and Appeals Form (coming soon)
    Use this form if you have a complaint about a service you got or do not agree with a decision we made.
  • Navigate HIPAA Authorization Form
    Use this form to share your health information with your providers or someone else
  • Member Request for Medication Exemption
    Use this form to send us a request for a drug not listed on your Preferred Drug List.
  • Tell Us (coming soon)
    Use this form when you would like to send us a question. You can also make a complaint, file an appeal or tell us if you have any other insurance.