Reimbursement and Claim Forms

*NOTE MEMBER'S NAME IS ALSO NECESSARY IN DEPENDANT CLAIMS*


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 Reimbursement Form

Please use this form for all Hospitalization claims.


Corrective Eye Surgery Reimbursement



Hearing Aid Reimbursement Form



Dental Claim Form

Active and retirees.