Brochures & Forms
Claim forms and brochures for Service Benefit Plan members.
FEP BlueDental® And FEP BlueVision®
2019 Plan Brochures
Medical and Dental
Health Benefits Claim Form
If you use a provider outside of the network, you will need to complete and file a claim form for reimbursement.
Overseas members should use the Overseas Medical Claim Form.
Dental Benefits Claim Form
If you take advantage of Service Benefit Plan dental benefits, you will need to complete and file a claim form for reimbursement.
Health Benefits Election Form (SF 2809 Form)
To enroll, reenroll, or to elect not to enroll in the FEHB Program, or to change, cancel or suspend your FEHB enrollment please complete and file this form.
Authorized Representative Designation Form
Use this form to select an individual or entity to act on your behalf during the disputed claims process. You can find detailed instructions on how to file an appeal in the Disputed Claims Process document.
Medicare Reimbursement Account (MRA) Pay Me Back Claim Form
Retail Prescription Drug Claim Form
Use this form to file a claim for reimbursement for retail prescriptions.
Overseas members should use the Overseas Retail Prescription Drug Claim Form.
Mail Service Prescription Drug Form
Use this form to order a mail order prescription. This is available for Basic Option members with Medicare Part B primary and Standard Option members only.
Formulary Tier Exception Member Request Form
For all formulary tier exceptions you will need to complete and file a request form.
Specialty Formulary Tier Exception Member Request Form
For all specialty formulary tier exceptions you will need to complete and file a request form.
Specialty Medication Order Form
Use this order form for specialty medications.
Primary Breast Cancer Prevention Coverage Member Request Form
Complete the Member Request Form for Primary Breast Cancer Prevention Coverage.
Prior Approval Pharmacy Forms
For more information about Pharmacy Prior Approval and the required forms visit the Prior Approval page.
Managed Formulary Exception Form
The Managed Formulary Exception (MFE) process allows Basic Option members to apply for coverage of a “Managed Not Covered” drug at a Tier 3 cost share if they have tried and failed the covered drug(s).
Standard Option Exclusion Form
The Standard Option exclusion process allows Standard Option members to apply for coverage of an excluded drug at a Tier 3 cost share if they have tried and failed the covered drug(s).
Non-Formulary Exception Form
The Non-Formulary Exception (NFE) process allows FEP Blue Focus members to request coverage of a non-formulary drug if they have tried and failed a covered option(s).
Dispense as Written (DAW) Exception Process
The Dispense as Written exception process allows for coverage of the brand drug without paying the difference in cost between brand and generic.
New to Market FDA-Approved Medication Review Exception Process
The New to Market FDA-Approved Medication Review Exception Process allows a member to apply for coverage of an excluded drug at a tier 3 cost share if the member has met the requirements outlined.
Overseas Medical Claim Form
Overseas members will need to complete and file this claim form for any medical services received.
Retail Prescription Drug Overseas Claim Form
GMMI Overseas Provider Nomination Form
Should you wish to request to recruit a facility or physician into the GMMI network, please complete this nomination form.
FEP BlueVision Claim Form
FEP BlueVision is neither offered nor guaranteed under contract with the FEHB Program, but is available to all enrollees and family members who become members of FEP BlueVision.
Need to Submit a Claim?Get step by step instructions on how to download and complete the appropriate form for health benefit claims, dental claims, Medicare Reimbursement Account claims, pharmacy claims, overseas claims and FEP BlueVision direct reimbursement claims.