Documents and Forms
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
Contraceptive Resources
- Preventive Services Reference Guide (preventive contraceptive guidelines and downloadable provider prior authorization form for contraceptive coverage exceptions)
- Provider Contraceptive Prior Authorization Instructions
- UPMC Health Beat (for contraceptive health information and articles)
Members can contact OPM at contraception@opm.gov for assistance with contraceptive coverage or questions.
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
- PSHB Complaint and Grievance Process
- 2024 FEHB Plan Brochure
- 2025 PSHB Open Season Benefit Guide
- 2024 FEHB Open Season Benefit Guide
- 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