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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.

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  • 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.

  • Infertility Treatment and Procedures Disclosure Form

    Request health insurance coverage for infertility treatment or procedures. 

  • 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.

  • Request for Personal Information

    Ask for information ConnectiCare has on file about you: medical and pharmacy claims history, authorizations, and premium billing.

  • HIPAA Privacy Release Form

    Written authorization required for ConnectiCare to release a member's personal health information to someone else.