Affidavit of Domestic Partnership
Legally establish a domestic partnership for the purposes of enrolling your partner on your health insurance plan.
Drug Claim Form
Coordination of benefits / Direct claim form.
Drug Mail Order Form
Medco Pharmacy order form.
Handicapped Certification Form
Certification of an unmarried child's handicap and eligibility for continued coverage.
Health Care Proxy Form
Complete this New York State document to legally appoint someone you trust, such as a family member or close friend, as your healthcare agent; to make healthcare decisions for you if you lose the ability to make decisions for yourself.
Medco Claim Form - Members
Claim form for use by non-Medicare Members.
Medco Claim Form - Medicare Members
Form for submitting claims to Medco for Medicare Members.
Medco Mail Order Form - Members
Non-Medicare members can use this form to order medication through Medco.
Medco Mail Order Form - Medicare Members
Signing up for the mail order option through Medco provides convenient home delivery of your prescription drugs and may also save you money.
Medicare Certification Form
This form is used to determine Medicare eligibility.
Student Dependent Verification Form
This form must be completed to verify that your dependent age 19 or over is a full-time student at an accredited College or University.
Subscriber Claim Form
Medical benefits subscriber claim form.
Vaccine Claim Form
Complete and submit for reimbursement of covered Part D vaccines and their administration.
Vision Claim Form
EyeMed out-of-network claim form.
Coverage Determination form
A beneficiary, a beneficiary's representative, or a beneficiary's prescriber may use this form to request a coverage determination (prior authorization, exception, etc.) from your Medicare Advantage plan.
A beneficiary, a beneficiary's representative, or a beneficiary's prescriber may use this form to request a redetermination (appeal) from your Medicare Advantage plan.