Coordination of Benefits (COB) Questionnaire Form (Use once your new 2021 Benefit Period begins)

Notify the Plan of other insurance coverage in order to determine the order of benefits/coverage. You can also submit this form by logging in to your Benefits Manager  and selecting 'Forms.'

Coordination of Benefits (COB) Questionnaire Form (Use if your Benefit Period began in 2020)


CVS Caremark Rx Claim Form

Get reimbursed for prescription drug claims. This includes submitting prescription receipts for secondary coverage to CVS Caremark.

HMS Spouse Employer Declaration Form 

As part of the HMS verification process, if your spouse is employed but does not have insurance coverage through their employer at this time, please have their employer complete this form. Once completed the form will be returned to HMS per the instructions on the form. Please make sure to include the participant’s identifying information at the top of the form before sending to HMS.

Medical Claim Form

Submit medical care claims to the Plan. Please be advised that no rights under the Plan, including but not limited to the right to receive any benefit or any right to pursue a Claim or cause of action, are assignable to another party. For more information see the "Authorized Representatives” section of the SPD.

Delta Dental Claim Form

Submit dental care claims if you are treated by a dentist who is not a member of Delta Dental. See instructions on how to submit this form.

Beacon Health Options Mental Health/Substance Abuse Treatment Claim Form

Submit this form for mental health/substance abuse treatment claims. You may also fill out and submit an online form on the Achieve Solutions website.

Health Insurance Claim Form

Health care providers can submit this form for services provided to patients.

Express Scripts Rx Claim Form

For claims prior to January 1, 2021, get reimbursed for prescription drug claims. Please use the Medical Claim Form if you are submitting prescription receipts under secondary coverage.