Administrative Changes

Administrative forms used to make changes can now be viewed and printed. Forms are in PDF format. You will need Adobe Acrobat to view and print a form. View a form by clicking on its title. Send completed forms to your Account Manager.

To print, click on the print icon in the Adobe Acrobat toolbar, located above the form. Please read the form instructions carefully to ensure your request is processed correctly, quickly and efficiently. If you have any questions, visit our Adobe Acrobat page.

Do you need to make an administrative change for which there is no form? Send a message to your Account Manager to request assistance.

Select a form:

COBRA Action Report I
Use when qualifying event is termination or reduction of hours

COBRA Action Report II
Use when qualifying event is death

Directory Order Forms
Request provider directories

Prescription Override Form
Request and authorize overrides in prescription policies

Claims Payment Exception Form
Request and authorize exceptions in claim payment policies