Important Forms

Request Reimbursement

In most cases, health care providers and pharmacies will file your insurance claims for you, and you will pay only your copay out of pocket. However, providers who are not part of the State Health Plan network will ask for full payment directly from you. In those cases, if the services are normally covered by the State Health Plan, you can request that your expenses be reimbursed.

Use the appropriate form below to request reimbursement from the State Health Plan.

PPO Plan Medical Claim Form
Use this form to request reimbursement for health care services, such as a visit to a doctor not in the Blue OptionsSM provider network. The Plan will only reimburse you up to the allowable, usual, customary, reasonable amount. Non-participating providers may bill you for the remainder of their charges.

PPO Worldwide International Claim Form
Use this form to request reimbursement for health care services when you receive care outside of the United States.

Prescription Drug Claim Form
Use this form to request reimbursement for prescription drugs, such as those not purchased from a pharmacy contracted with the State Health Plan. Your reimbursement will be the Plan's maximum allowable amount, not the charge for the prescription drug.

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