• Summary Plan Descriptions
• Forms: For Members
• Forms: For Providers
• Forms: For Employers
• Newsletters
• Eligibility

Forms: For Providers

 

• Provider Demographic Information Change Request Form

• Provider Recruitment Form

 

• Services Requiring Pre-Authorization

• Ambulatory Surgical Procedures Requiring Prior Authorization

• Chiropractic Services-(refer to Quick Reference Contact Sheet)
• Homecare, Certain Outpatient, DME and RX Services
• Hospital Services - (refer to Quick Reference Contact Sheet)

 

• Reference Contact Guides
• Chiropractic Services
• Hospital Services
• Outpatient &Homecare Services
• Prescription Benefit Program

 

• Forms for Authorization
• Service/Equipment Request for Authorization
• Home Oxygen Therapy Request for Authorization
• Prescription Request for Authorization
• PT/OT/ST Benefit Extension