Anthem/CarelonRx Prescription Coverage - For High Deductible Health Plans (HDHP)

Anthem CarelonRx Mail Service Order Form [1.01 Mb]
Anthem CarelonRx Prescription Reimbursement Claim Form [183 Kb]

Benefit Advantage FSA/HRA Services

Benefit Advantage List of Eligible Expenses [58 Kb]
Change in Status Form [281 Kb]
Direct Deposit Authorization Form [53 Kb]
Election Worksheet [74 Kb]
FSA Claim Form [244 Kb]
Physician Statement [105 Kb]
Void & Reissue Form [372 Kb]

Claims

Anthem Subscriber Claim Form [46 Kb]
CVS Caremark Prescription Reimbursement Claim Form [171 Kb]
Northeast Delta Dental Claim Form [747 Kb]
STD-Disability Income Benefits, Claim and Disability Status Form [293 Kb]

CVS Caremark Prescription Coverage

CVS Caremark Mail Service Order Form [318 Kb]
CVS Caremark Prescription Reimbursement Claim Form [171 Kb]

Flyers

Benefit Advantage FSAs - Information for Employees [1.48 Mb]

Life, Long-Term Disability and Short-Term Disability Enrollment

Life LTD STD Fillable Application Form [134 Kb]

Medical and Dental Enrollment

Annuity Deduction Authorization for Medical and Dental Benefits Fillable Form [433 Kb]
Anthem Site of Service ASC Listing [59 Kb]
Anthem Site of Service Lab Listing [103 Kb]
Certificate of Tax Dependent Status for a Domestic Partner [363 Kb]
Certification for a Mentally or Physically Disabled Dependent Child Over Maximum Age [1.35 Mb]
COBRA Coverage ACH Authorization Form [108 Kb]
Dental Application and Change Fillable Form [213 Kb]
Domestic Partner Statement of Termination [143 Kb]
Domestic Partners Affidavit [138 Kb]
Information Update/Correction Form [235 Kb]
Medical and/or Dental Application and Change Fillable Form [265 Kb]
Notice of Divorce or Legal Separation [129 Kb]
Notice of Membership Changes Fillable Form [345 Kb]
Retiree Medical and/or Dental Application and Change Fillable Form [209 Kb]

Medicare Supplemental Plan (Medicomp Three)

Medicomp Three brochure [121 Kb]
Retiree ACH Authorization Form Fillable PDF [69 Kb]

Privacy and Security (HIPAA)

HIPAA Authorization to Release Information [172 Kb]
Instructions for Completing HIPAA Authorization to Release Information Form [107 Kb]
Notice of Privacy Practices [159 Kb]
Notice of Privacy Practices - ComPsych Corporation [33 Kb]
Request for Accounting of Disclosures [33 Kb]
Request for Confidential Communications [27 Kb]
Request for Restriction on Uses and Disclosures [33 Kb]
Request to Amend a Record [33 Kb]
Request to Inspect Health Information [34 Kb]
Revocation of Authorization to Release Information [29 Kb]
Secure Member Portal Authorized User Access Form [120 Kb]
Termination of Restriction on Use and Disclosures [28 Kb]

Provider Directories

Anthem Site of Service ASC Listing [59 Kb]
Anthem Site of Service Lab Listing [103 Kb]

Requirements and Helpful Hints

Helpful Hints When Completing The Annuity Deduction Authorization for Medical and Dental Benefits Form [407 Kb]
Helpful Hints When Completing the Medical and/or Dental Application and Change Form [215 Kb]
Helpful Hints When Completing the Retiree Medical and/or Dental Application and Change Form [224 Kb]

Wellness Coordinator Forms and Resources

2026 Wellness Coordinator Application [128 Kb]