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

Contraceptive Resources

• Preventive Services Reference Guide (preventive contraceptive guidelines and downloadable provider prior authorization form for contraceptive coverage exceptions)
• Provider Contraceptive Prior Authorization Instructions
• UPMC Health Beat (for contraceptive health information and articles)
• FEHB contraceptive page

Members can contact OPM at contraception@opm.gov  for assistance with contraceptive coverage or questions.