Documents & Forms

We've put together the most common documents and forms you might need for things like filing claims or reviewing your coverage. Start by choosing what kind of insurance you have from the list below.

Through Your Employer

Your plan falls into this category if you get your health insurance through your employer.

Claims
Use these forms if you'd like to submit a claim.
Breast Pump Claim Form
Medical Claim Form
Vision Claim Form
Dental Claim Form
Prescription Claim Form
Benefits & Coverage
These documents contain information about your benefits, network and coverage.
In-Network Benefit Request Form
Federal/Postal Employee Programs In-Network Benefit Request Form
Prior Authorization List
Provider Directory
Medical Policy Manual
Pharmacies & Prescriptions
These documents offer information about your covered drug benefits.
2026 Essential Medication List (Formulary)
2026 Preferred Medication List (Formulary)
Mid-Year 2026 Formulary Changes
2026 Essential Plus Medication List (Formulary)
2026 BlueCross Preventive Medication List
2026 Choice Medication List (Formulary)
2026 Control Medication List (Formulary)
2026 Control and Choice Preventive Drug List
Prescription Exception Request Form
Preferred Specialty Pharmacy Network List
Exclusive Specialty Pharmacy Network
Provider-Administered Specialty Drug List
Provider-Administered Specialty Medication Step Therapy Guide
Medical Exclusions Medication List
Over the Counter Savings Drug List
ACA $0 Copay Drugs & Contraceptives List
Rules for When We Cover Opioids
Prescription Mail Service Order Form
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Health Spending Accounts
These documents offer information about your health accounts and financial arrangements.
HRA/FSA Direct Deposit Form
HRA Claim Form
Health Care FSA Claim Form
Dependent Care FSA Claim Form
Limited-Purpose FSA Claim Form
FSA Eligible Medical Expenses
Health Care FSA Brochure
Dependent Care FSA Brochure
Limited-Purpose FSA Brochure
FSA Worksheet
HRA Brochure
HSA Brochure
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Your Rights
You'll find notices and forms in this section that will help you understand your rights and responsibilities, and make requests related to those rights.
Notice of Privacy Practices
Request to View Records
Request to View Records (Spanish)
Request to Amend Records
Request to Amend Records (Spanish)
Request to Disclose Records
Request to Disclose Records (Spanish)
Request Alternative or Confidential Communication
Request to See Information Disclosures
Request Personal Representative
Request Personal Representative (Spanish)
Grievance Form
Grievance Form (Spanish)
ERISA Disclosure Request
ERISA Disclosure Request (Spanish)
Privacy Complaint
Privacy Complaint (Spanish)
Request to Restrict Our Use or Disclosure of Health Information
Request to Restrict Our Use or Disclosure of Health Information (Spanish)
Request Interpreter Services in Another Language
Subrogation Questionnaire
Subrogation FAQs
Surprise Billing Patient Disclosure Notice
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Individual & Family

Your plan falls into this category if you shopped on healthcare.gov, worked with a broker or bought your plan directly from us.

Documents & Forms

Billing

Benefits & Coverage

Pharmacies & Prescriptions

Health Savings Account

Your Rights

Enrollment

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