Forms and Information

Information

• Questions and Answers
• Accidents and Injuries
• Capitated services
• Copays and coinsurance
• Eligibility
  • Eligibility calculator
  • Continuing eligibility calculator
• Health Link newsletter
• How to sign up for the Participant Portal
• Medical and coverage definitions
• Optum Specialty Pharmacy Specialty Drug List
• Participating employers
• Participating unions
• Self-pay
• What to do if you get hurt at work

Documents and Guides

• Copay Book
• Dental Book
• Diabetes
  • Blood Sugar Log
  • Diabetes Passport Booklet
  • Diabetes Portion Control Containers Guide
  • Healthy Ways to Eat Carbs with Diabetes
  • How to Shop Healthy with Diabetes
  • Lowering Your Blood Pressure with DASH
  • Sample Diabetes Healthy Carb Menus
• Participant Guide
• Pharmacy
  • Drugs available at the Culinary Pharmacies
  • Preferred drug list
  • Optum Specialty Pharmacy Specialty Drug List
• Vision Benefit Summary

Notices

• Medicare Part D notice
• Summary Annual Report (SAR)
• Summary of Benefits and Coverage (SBC)
• Summary Plan Description (SPD)
• Tax information
• Womenʼs Breast Cancer Annual Notice
• Your Rights and Protections Against Surprise Medical Bills

Forms

• Accident inquiry form
• Appeal request form
• Authorization for release of protected health information (PHI)
• Continuity of Care Request Form
• Copay Waiver Request Form
• Disenrollment form
• Extended Eligibility Application
• Life Insurance Beneficiary Form
• Medical/​Vision Claim Form
• Non-Union to Union Classification Transfer Form

• Open Enrollment

  • Open enrollment packet
    • Open enrollment form
    • Life insurance beneficiary form
    • Private health survey
• Repayment agreement
• Retiree enrollment application

• Subrogation

  • Subrogation packet
    • Accident inquiry form
    • Repayment agreement
    • Statement of facts
    • Authorization for the release of Protected Health Information (PHI)