Member forms and resources

Here you’ll find information that can help you manage your plan – including forms for your FSA, HRA or Empower plan – plus other resources.

Medical, dental and pharmacy forms

Please note: If you need to submit a medical or dental claim , you may be able to do so in your online account .

• Medical coordination of benefits form (PDF)
• Dental coordination of benefits form (PDF)
• Dental out-of-network reimbursement form (PDF) (Medicare plans only)
• Pharmacy claim form (PDF)
• Pharmacy prior authorization/exception request form (PDF)
• Travel benefit claim form (PDF) (certain plans only)

You can also access additional specialized forms , like insurance coverage verification, in your online account.

Forms for spending accounts (FSAs, HRAs, Empower plans and other reimbursement accounts)

Please note: You can submit an FSA or HRA claim through your online account without filling out a paper form. You can also learn more about how FSAs work or how HRAs work .

• Automatic claims submission opt-out request form (PDF)
• Direct deposit form (PDF)
• FSA/HRA claim form (PDF)
• Letter of medical necessity form (PDF)

More forms for members with an employer-based Empower FSA or HRA, or other reimbursement account

• Dependent care expense claim form (PDF)
• Spending account enrollment/election form (PDF)
• Transportation and parking expense claim form (PDF)

Employer forms

If you’re an employer, see our employer forms for resources and tools for your group health plan.