Forms and Translated Materials


Appointment of Representative
Authorization to Disclose Protected Health Information
Automated Premium Payment (ACH) Form
Prescription Drug Mail-Order Form
Prescription Drug Claim Form
Prior Authorization
Request for Medicare Prescription Drug Coverage Determination Form
Request for Redetermination of Medicare Prescription Drug Denial Form
Physician Fax Form
File a Grievance (Please select your health plan and health plan type for information about filing a grievance.)
Step Therapy Form

en Español

Alternate formats for these materials, including Spanish translations, may be available. Please contact our Product Specialists for additional information.

Este material está disponible en otros formatos, incluida la traducción al Español. Contacte nuestro numero de Servicio al Cliente para obtener información adicional.

Materials in English - 2014 Materiales en Español - 2014

Summary of Benefits
Accepted 10012013

Summary of Benefits en Español
Accepted 10012013

Drug List - PPO
Accepted 10012013

Drug List - PPO en Español

Pharmacy Directory
Accepted 10012013_TX

Pharmacy Directory en Español
Y0096_BEN_TMP_MAPHAR14SPA Accepted 10012013

Evidence of Coverage- PPO
Accepted 08292013

Evidence of Coverage- PPO en Español
Approved 08222013


Materials in English - 2013 Materiales en Español - 2013

Summary of Benefits  
H1666_TX_BEN_BNFTSMRY13 Accepted 09152012

Summary of Benefits en Español 
H1666_TX_BEN_BNFTSMRY13SPA Approved 09152012

Drug List  

Drug list en Español  

Pharmacy Directory  
H1666_BEN_TMP_RXDRCTRY13a Accepted 10012012

Pharmacy Directory en Español
H1666_BEN_TMP_RXDRCTRY13aSPA Accepted 10012012

Evidence of Coverage - Plan 001
H1666_BEN_TX_EOC0012013 Accepted 09042012

Evidence of Coverage - Plan 001 en Espanol

Evidence of Coverage - Plan 002
H1666_BEN_TX_EOC0022013 Accepted 09042012

Evidence of Coverage - Plan 002 en Espanol

Evidence of Coverage - Plan 003
H1666_BEN_TX_EOC0032013 Accepted 09042012

Evidence of Coverage - Plan 003 en Espanol
H1666_BEN_TX_EOC0032013SPA Accepted 09042012