Forms
Below are some useful resources and forms for each of the plan options.
2026 Plan Documents
2025 Plan Documents
2026 Medicare Rx (PDP) Documents
2025 Medicare Rx (PDP) Documents
Plan Forms
- Coordination of Benefits (PDF)
- HSA/HRA Selection Form (PDF)
- Medical Claim Form (PDF)
- Prescription Mail Order Form (PDF)
- Prescription Reimbursement Claim Form (PDF)
- Social Security Number Submission Form (PDF)
- Vision Claim Form - Davis (PDF)
- International Claim Form (PDF)
(for members receiving care outside of the U.S.)