Need a claims form? If you use a provider or hospital that participates in the Service Benefit Plan network, you will not have to fill out any claim forms - the provider will take care of it for you. In situations where you use a provider outside of the network, receive care overseas or require prior approval for a medication, you will need to complete and file a claim form to be reimbursed by your health plan.
To download these forms online, choose from the menu below.
Health Benefits Claim FormEnglish [PDF 79 KB]En Español [PDF 194 KB]
Dental Benefits Claim FormEnglish [PDF 125 KB]
Retail Pharmacy Claim FormEnglish [PDF 175 KB]En Español [PDF 74 KB]
Mail Service Prescription Drug Form (Standard Option only)English [PDF 1 MB]En Español [PDF 1 MB]
Overseas Medical Claim Form
Overseas Retail Pharmacy Claim Form
Formulary Tier Exception Member Request Form
2013 AXA Provider Nomination Form
Health Benefits Election Form (SF 2809 Form)
Prior Approval Retail Pharmacy Forms
For more information about Pharmacy Prior Approval and the required forms visit CVS Caremark Prior Approval page.
Page last updated: March 28, 2013