Forms and Documents

2026 Employer Sponsored Health Coverage

Summary of Benefits and Coverage (SBC) 

A clear, easy to read summary of covered services and what you pay for common types of care.

English

Spanish

Evidence of Coverage (EOC) 

The full legal document that describes your benefits, covered services, exclusions, and member rights.

English

Spanish

Schedule of Benefits (SOB) 

A detailed breakdown of copays, deductibles, and coinsurance amounts.

English

Spanish

Formulary 

A list of prescription medications covered by your plan, including coverage tiers and requirements.

English

Spanish

Provider & Pharmacy Search Tools 
Provider & Pharmacy Directory 

The Provider and Pharmacy Directory is needed so members can confirm in‑network providers and pharmacies and avoid unnecessary out‑of‑network costs.

English

Spanish

Additional Forms and Documents

24 Hour Nurse Line 

Health plan members can call 844‑581‑3175 to speak with a registered nurse anytime—24/7, 365 days a year. Nurses can help answer health questions, discuss medications, and guide care decisions. If you are experiencing a medical emergency, please dial 911 or go to the nearest emergency room.

Authorization to Disclose Personal Information  

This form authorizes the release of your protected health information to a designated third party, such as a family member or friend. It provides specific options to share sensitive records, including behavioral health or substance abuse data, if you choose to include them. You can revoke this permission in writing at any time.

Glossary of Terms  
Medical Reimbursement Form  

This form is used to request reimbursement for out-of-network medical services that were paid for out-of-pocket. You must submit this form and all supporting documentation within 365 days of service. Once submitted, it typically takes up to 30 days for the request to be uploaded and processed. You can check the status of your claim through your member portal under the “Claims” section.

RX Claim Form  

This form is used to request reimbursement for prescription drugs you paid for out-of-pocket. Claims must be submitted within 365 days of the date of service.

Transplant Travel Claim Form  

This form is used to request reimbursement for travel, lodging, and meal expenses related to approved transplant services located 61 miles or more from your home. Travel claims must be filed no later than 365 days after the qualifying travel date.

Last Updated Date: 6/22/26