|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.|
|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.|
|To file an appeal (request for us to consider our decision) or a grievance about any service received from one of our network providers.|
|**Use it to request reimbursement for covered medications purchased at retail cost. Complete one form per member.|
|**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.|
|Use it to request a reimbursement for in-country and foreign covered medical expenses. Additional paperwork may be required. (Examples. Receipts, itemized invoices/bills and others.) Please contact Costumer Service for more information.|
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.