2021 Documents and Forms

Medical benefits

California Medical Benefits

• Side by side benefit comparison
• Summary of Benefits and Coverage (SBC)
• Summary of Benefits and Coverage (SBC) – AHRO and AHMC associates
• Summary of Benefits and Coverage (SBC) – Delano associates
• Summary Plan Description (SPD)
• Summary Plan Description (SPD) - AHRO and AHMC associates
• Summary Plan Description (SPD) - Delano associates

Oregon Medical Benefits

• Side by side benefit comparison
• Summary of Benefits and Coverage (SBC)
• Summary Plan Description (SPD)

Legal and Privacy notices

• Omnibus
• Privacy notice

Global Emergency Services

Pharmacy benefits

• Pharmacy Benefit
• Zero Dollar Copay Medication List
• Community Partner Pharmacy List
• OptumRx Formulary
• OptumRx Claim Form
• How to create an OptumRx account
• Preventive Care Medications
• Free glucose monitor

Forms

• Unavailable Service Request form
• Medical Claim form
• Pharmacy Claim form
• Coordination of Benefits/Other Insurance form
• General Authorization Designation of Personal Representation and Email Consent form