Reimbursement and Claim Forms

Note: Members's Name must be included when filing for dependant

Annual Prescription Drug Benefit Claim Form & Instructions
Up to $150 payable. Submission by January 15th of following year.

Non-Participating Optical Reimbursement Form
With guidelines for submitting request for payment.

Hospital Stay Reimbursement Form

Corrective Eye Surgery Reimbursement

Hearing Aid Reimbursement Form

Dental Claim Form
Active and retirees.