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Forms 2022

Click here for 2021 Forms

Form Name Description
Coverage Determination
Use it to request that we cover a prescription not currently included in the plan in which a member is enrolled. A doctor typically fills this out for the member.
Appointment of Representative
**See below for instructions on how to appoint a representative
Used to appoint any individual, including an attorney, to represent a member during the processing of a claim or claims, and/or any subsequent appeal or in connection with any aspect of dealing with an insurance provider.
Member Grievance and Appeal
To file an appeal (request for us to consider our decision) or a grievance about any service received from one of our network providers.
Prescription Reimbursement
**OptumRx Form
**Use it to request reimbursement for covered medications purchased at retail cost. Complete one form per member.
Mail Order
**OptumRx Form
**Use it to place your order for prescription drugs through the mail. You may find using a mail-order pharmacy to be a cost effective and convenient way to fill prescriptions for drugs you take every day.

**Appoint a representative

You can ask someone to act on your behalf. If you want to, you can name another person to act for you as your "representative" to ask for a coverage decision or make an appeal.

  • There may be someone who is already legally authorized to act as your representative under State law.
  • If you want a friend, relative, your doctor or other provider, or other person to be your representative, fill out the form to give that person permission to act on your behalf. The form must be signed by you and by the person who you would like to act on your behalf. You must mail the signed form to the Member Services Department