EXC-SHP-Print Forms

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.

Claim Forms

Flexible Spending Account or Medical Reimbursement Account

General Forms

Membership & Enrollment Forms

Reimbursement Forms

Some forms may not apply to your coverage and benefits. To obtain other forms not listed here, please contact Customer Services.

GLO-Print Forms - 1095B sidebar

Form 1095-B

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.

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