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 |
|
| HIPAA Release of Information | ||
| Email Opt-In Form | Click Here |
|
| Vision Reimbursement Form | ||
| Update Your Address | Click Here | |
| Optum Rx Mail Service Order Form | ||
| Automated Monthly Premium EFT Authorization Form | English | Español | |
| Premium Withhold Option Form | English | Español | |
| Appointment of Representative | English | Español | |
| Over-the-Counter (OTC) Order Form | English |
Need Answers?
Call our Concierge team at 713-442-CARE (2273) or toll-free at 1-866-535-8343 (TTY: 711).
From January 1 to March 31
8 a.m. – 5 p.m.
Monday – Friday
From April 1 to December 31
8 a.m. – 8 p.m.
Monday – Friday
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