Medical

Medical Plan Forms

Get help using 'Medical Plan Forms'

  • Medical Forms

    Waiver of Health Insurance
    Required
    15. Health Insurance Waiver.pdf
    Medical Enrollment & Change Form
    Required
    1. Cigna Medical Enrollment Form.pdf
    Medical Claim Form
    Required
    R450-2778hb_MedicalClaimForm_v5.pdf
    While focused on a reorder icon, press the Enter key or spacebar to "select" the icon. While a reorder icon is selected, pressing the up and down arrows will change the order of the selected item within the list. Pressing Enter key or spacebar again will drop the selected item at that location in the list.

  • Inspira Financial

    Inspira FSA/DCA Enrollment Form
    Required
    5. Inspira FSA Enrollment Form.pdf
    Inspira Health Savings Account (HSA) Payroll Deduction
    Required
    6. Inspira HSA Enrollment Form.pdf
    Payflex Health Savings Account (HSA) Form
    Required
    4. Payflex HSA Enrollment Form.pdf
    While focused on a reorder icon, press the Enter key or spacebar to "select" the icon. While a reorder icon is selected, pressing the up and down arrows will change the order of the selected item within the list. Pressing Enter key or spacebar again will drop the selected item at that location in the list.

  • OptumRx

    OptumRX Mail Order Prescription Form
    Required
    MULTI-OptumRx-Home-Delivery-mail-order-form.pdf
    OptumRX Prescription Claim Form
    Required
    OptumRX Claim Form.pdf
    2025 Premium Standard Formulary

    Information about the premium formulary, including a non-exhaustive list of covered medications and their corresponding prescription tier.

    Required
    January 2025 B2C Cycle Premium_Standard_Closed Formulary.pdf
    While focused on a reorder icon, press the Enter key or spacebar to "select" the icon. While a reorder icon is selected, pressing the up and down arrows will change the order of the selected item within the list. Pressing Enter key or spacebar again will drop the selected item at that location in the list.
While focused on a reorder icon, press the Enter key or spacebar to "select" the icon. While a reorder icon is selected, pressing the up and down arrows will change the order of the selected item within the list. Pressing Enter key or spacebar again will drop the selected item at that location in the list.