Call Member Services at 713-442-CARE (2273)
or toll-free at 1-866-535-8343 (TTY: 711)
Member Forms
If you need assistance completing a form or have questions about which form to complete, please call member services at 713-442-2273.
| Form Name | Online Form | PDF Download |
| Part D Coverage Determination/Appeal Request | Click Here | |
| Part D Coverage Redetermination | Click Here | |
| Part D Direct Member Reimbursement Form | ||
| Other Coverage Questionnaire | Click Here |
|
| Appointment of Representative (AOR) | ||
| HIPAA Release of Information | ||
| Email Opt-In Form | Click Here |
|
| Vision Reimbursement |
|
|
| Update Your Address | Click Here | |
| CVS Caremark Mail Service Order Form |