Reimbursement Forms
Other Claim Forms
- Out-of-Network Care Claim Form
- Prescription Drug Claim Form Medicare Part D (Form is for flu shot reimbursement)
- Health Reimbursement Arrangement (HRA) Claim Form (Form is for prescription reimbursements only)
- ESI Mail-Order forms
- Transition of Care Form
Health Incentive Account Submission Form
Provider Network Forms
HIPAA Privacy Forms
- Notice of Privacy Practices
- Personal Representative Designation Form
- Member Authorization to Use or Disclose Protected Health Information
Updates to preventive guidelines can occur throughout the benefit year. Please check the following websites for any changes and updates:
Other Helpful Information
- Family Member Eligibility Form
- Assist America Brochure
- Fast Facts: Health Care Coverage Forms for Federal Employees
- Fast Facts: Health Care Coverage Forms for Annuitants
- FEHB Complaint and Grievance Process
- 2024 Plan Brochure
- 2023 Open Season Benefit Guide
- 2024 Open Season Benefit Guide
- 2023 Pharmacy Formulary
- 2024 Pharmacy Formulary
- Prescription Drug Rider
- Infertility Treatment and Diagnosis MP
- Maternity Program
- Prescription Drug Price Tool
- Notice of Protection Provided by Pennsylvania Life and Health Insurance Guaranty Association
- Your Rights and Protections Against Surprise Medical Bills
- Consumer Protections (opm.gov)
- ReproductiveRights.gov – Know Your Rights: Reproductive Health Care
- COVID-19 Reimbursement Letter