Forms

Tell Us: 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.

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: 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,

DisposeRx^® Request Form: Get a free DisposeRx packet to help you dispose of unused or expired medications.