Enrollment Change of Status (ECOS)

Membership Changes - adds, terms, address changes, etc.

Employee Waiver

Employee waiver form.

Option Care Mail Order

Order specialty drugs via mail order through Option Care.

Medco Mail Order

Order non-specialty drugs vial mail order through Medco.

COB

Coordination of Benefits - Online Form.

Privacy-Authorization Form PHI

Approve the release of your protected health information (PHI) to a person or entity of your choice.

Privacy-Authorization Revocation Form

To revoke your prior authorization release.

Claim Forms