Documents and Forms

Reimbursement Forms

• Flu Shot Reimbursement Form
• Medicare Part B Premium Reimbursement Form
• Medicare Part B Premium Reimbursement Form (PDF)
• Medicare Part B Direct Deposit Form (PDF)

Other Claim Forms

• Out-of-Network Care Claim Form
• Prescription Drug Claim Form Medicare Part D (Form is for flu shot reimbursement)
• Health Reimbursement Arrangement (HRA) Claim Form (Form is for prescription reimbursements only)
• ESI Mail-Order forms
• Transition of Care Form

Health Incentive Account Submission Form

• Health Incentive Account Submission Form

Provider Network Forms

• Provider Nomination Form

HIPAA Privacy Forms

• Notice of Privacy Practices
• Personal Representative Designation Form
• Member Authorization to Use or Disclose Protected Health Information

Updates to preventive guidelines can occur throughout the benefit year. Please check the following websites for any changes and updates:

• U.S. Preventive Services Taskforce (USPSTF)
• Advisory Committee on Immunization Practices (ACIP)
• Health Resources and Services Administration (HRSA)
• Bright Futures

Other Helpful Information

• Family Member Eligibility Form
• Assist America Brochure
• Fast Facts: Health Care Coverage Forms for Federal Employees
• Fast Facts: Health Care Coverage Forms for Annuitants
• FEHB Complaint and Grievance Process
• 2024 Plan Brochure
• 2023 Open Season Benefit Guide
• 2024 Open Season Benefit Guide
• 2023 Pharmacy Formulary
• 2024 Pharmacy Formulary
• Prescription Drug Rider
• Infertility Treatment and Diagnosis MP
• Maternity Program
• Prescription Drug Price Tool
• Notice of Protection Provided by Pennsylvania Life and Health Insurance Guaranty Association
• Your Rights and Protections Against Surprise Medical Bills
• Consumer Protections (opm.gov)
• ReproductiveRights.gov – Know Your Rights: Reproductive Health Care
• COVID-19 Reimbursement Letter