Use the links below to print/view copies of our most frequently used forms.
Prescription Claim Forms
For compound drugs to be considered for reimbursement by the plan, each ingredient of the compound must be found and payable in our claims system. Members who choose to pay out-of-pocket for compounded drug products will not be reimbursed if the compound contains an ingredient that is not able to be identified and payable in our claims system.
- Prescription Drug Claim FormOpen a PDF - Use for prescriptions that were purchased on, or after, Jan. 1, 2017 and/or reimbursement for covered at-home COVID-19 tests. Refer to instructions on how to complete and submit for reimbursement of covered at-home COVID-19 testsOpen a PDF.
- Deluxe Item Upgrade Form
- Dental Claim Form
- International Claim FormOpen a PDF - Updated claim form is for use starting on Jan. 1, 2017 when submitting expenses incurred from rendering medical services overseas. Claims should not be submitted before the effective date.
- International Claim Form in Spanish Open a PDF
- International Claim Form in European A4 Paper SizeOpen a PDF
- Medical Claim FormOpen a PDF - Use to submit medical services from a provider, hospital, DME vendor, etc. Also use for vision services including eyewear. Do not use to submit prescription drug services. All prescription drug services should be submitted on the prescription drug claim form.
- Surprise Bill Certification FormOpen a PDF - Use this form if you receive a surprise bill for health care services.
FSA, HRA, and HSA Reimbursement Forms
- Reimbursement Account Forms (FSA/HRA/HSA) - Forms provided by Lifetime Benefit Solutions for Flexible Spending Account, Health Reimbursement Account, and Health Savings Account
Membership & Enrollment Forms
- Adult Disabled Dependent FormOpen a PDF
- Away From Home Care Guest Membership ApplicationOpen a PDF
- Continuing Coverage for Students on Medical Leave FormOpen a PDF
- Dental Coverage Attestation Form Open a PDF
- Dependent Certification FormOpen a PDF
- Healthy New York Recertification Open a PDF
- Member Change Form for Direct Purchase PlansOpen a PDF
- Prior Coverage Verification FormOpen a PDF
- Young Adult Option Certification FormOpen a PDF
Some forms may not apply to your coverage and benefits. To obtain other forms not listed here, please contact Customer Services.
Taxpayers are not required to include a Form 1095-B when filing their taxes.
Health insurers are no longer required to mail Form 1095-B to their members.
Click Learn More for your options.