Text Size: A A A

Forms/Resources

We have free interpreter services to answer any questions you may have about our health or drug plan.  Learn more.

Enrollment and Coverage Changes

If you are not enrolled in the Health Options Program: Application Form (PDF 97K)

If you are enrolled in the Health Options Program and looking to change your coverage: Change Form (PDF 108K)

Claims

Health Options Program Major Medical Claim Form (PDF 280K)

Health Options Program (MetLife) Dental Claim Form (PDF 675K)

Submit EyeMed (vision) claims through the online claim form or by logging in to the member area of the EyeMed website.

Prescription Drug Plan Forms

Health Options Program (OptumRx) Prescription Drug Claim Form (PDF 457K)

Health Options Program (OptumRx) Prescription Drug Prior Authorization Form (PDF 310K)

Health Options Program (OptumRx) Prescription Drug Mail Service Pharmacy Order Form (PDF 496K)

CMS Appointment of Representative Form (Form CMS-1696) (PDF 73K)

Last modified 2023-01-19