Forms

All common forms are available here for download. If you need any other type of form or if you have any questions about the Plan which you wish to discuss, please contact the Plan Administrator at 419-255-5314.

  Medical Form

  HCFA 1500 Form

  Dental Form

  Application for Consideration by Hardship Committee

  Eligible Dependents

PRESCRIPTION
  Medvantx Mail Order 

  Prescription Drug Claim Form

  RESTAT Formulary

  RESTAT Formulary (by Class)

  Formulary May Announcement

  Quarterly Formulary Update

  Step Therapy


VISION
Spectera Coordination of Benefits

NUTRITION
Nutrition Assessment Form

 

 

Healthy Living Tip

Dehydrated? Avoid sodas and alcohol. Best ways to rehydrate are water or fruit juice.
See all Tips

Q & A

What should I have ready when I call the Plan office?

Please have you ID card and any documents regarding the claims or issue you are calling to discuss. More