Medical

Medical Plan Forms

Get help using 'Medical Plan Forms'

  • Medical Forms

    Name Description Status Source
    Waiver of Health Insurance Required 15. Health Insurance Waiver.pdf Edit Waiver of Health Insurance Delete Waiver of Health Insurance
    Medical Enrollment & Change Form Required 1. Cigna Medical Enrollment Form.pdf Edit Medical Enrollment & Change Form Delete Medical Enrollment & Change Form
    Medical Claim Form Required R450-2778hb_MedicalClaimForm_v5.pdf Edit Medical Claim Form Delete Medical Claim Form
    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

    Name Description Status Source
    Inspira FSA/DCA Enrollment Form Required 5. Inspira FSA Enrollment Form.pdf Edit Inspira FSA/DCA Enrollment Form Delete Inspira FSA/DCA Enrollment Form
    Inspira Health Savings Account (HSA) Payroll Deduction Required 6. Inspira HSA Enrollment Form.pdf Edit Inspira Health Savings Account (HSA) Payroll Deduction Delete Inspira Health Savings Account (HSA) Payroll Deduction
    Payflex Health Savings Account (HSA) Form Required 4. Payflex HSA Enrollment Form.pdf Edit Payflex Health Savings Account (HSA) Form Delete Payflex Health Savings Account (HSA) Form
    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

    Name Description Status Source
    OptumRX Mail Order Prescription Form Required MULTI-OptumRx-Home-Delivery-mail-order-form.pdf Edit OptumRX Mail Order Prescription Form Delete OptumRX Mail Order Prescription Form
    OptumRX Prescription Claim Form Required OptumRX Claim Form.pdf Edit OptumRX Prescription Claim Form Delete OptumRX Prescription Claim Form
    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 Edit 2025 Premium Standard Formulary Delete 2025 Premium Standard Formulary
    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.