In this section
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 |
|
| 2024 Vision Reimbursement | Download - English Download - Spanish |
|
| Update Your Address | Click Here | |
| CVS Caremark Mail Service Order Form | ||
| Automated Monthly Premium EFT Authorization Form | Download | |
| Premium Withhold Option Form | Download |
Need Answers?
Call our Concierge team at 713-442-CARE (2273) or toll-free at 1-866-535-8343 (TTY: 711)
From October 1 to March 31
8 a.m. - 8 p.m.
7 days a week
From April 1 to September 30
8 a.m. - 8 p.m.
Monday - Friday