Plan Forms for Members

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Find benefit summaries, lists of covered drugs(formularies), and all necessary forms to get the most out of your ConnectiCare coverage.

Looking for Medicare forms and documents?


Looking for Access Health CT plan documents?

Looking for SOLO plan documents?

  • Member Information Update Form

    Update a Social Security number for you or a dependent for  IRS Form 1095-B.

  • Enrollment/Change Form

    Fill out to make many changes such as adding a dependent, electing COBRA, name or marital status change. Want to do it faster? You can make some changes on our secure member website. Sign in

  • Disabled Dependent Form

    Request continued ConnectiCare health care coverage for a disabled dependent who has reached the maximum dependent age limit.

  • Prescription Drug Reimbursement Claim Form

    Request reimbursement for prescriptions purchased without your ConnectiCare identification (ID) card.

  • Out-of-Plan Reimbursement Form

    Request reimbursement for a medical service you paid for or you received from an out-of-network provider; request coordination of benefits with you primary insurance company.

  • COBRA Election Notice Form

    Complete to choose COBRA coverage through a former employer.

  • Claim Pre-Estimate Form

    Fill out to see how much a service or treatment will cost you.

  • Authorization to Use and Disclose Protected Health Information - ConnectiCare

    Authorization, Verification and Certification Forms Authorization to Use and Disclose Protected Health Information. A written authorization is required for your plan to share a member's protected health information with anyone, except as required or permitted by law.

Preauthorization Check Tool

Want to see if your procedure requires a preauthorization? We have a resource for that.

It’s a quick form that tells you whether a preauthorization is needed for specific services. 

You will need your member ID and the following details from your provider before you can use the tool:

  • Procedure Code—also known as CPT or HCPCS Code
  • Diagnosis Code
  • Place of Service—where the services will be performed. 

Click the button below to launch the tool and enter the requested information to see if you need to get a preauthorization ahead of your procedure. 

Remember, you never have to get a preauthorization for emergency services. 

If you have any questions, please contact us here or at the number on your ID card.