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Medical Claims Forms

Medical Claim Form
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Authorization/Precertification Form
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Prescription Resources

Preferred Drug List
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Step Therapy
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Prescription Forms

Prescription Appeal Form
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Prescription Claim for Compound Medications
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Prescription Claim Form
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Quantity Limit Exception Request
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Prescription Prior Authorization
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Formulary Prescription Exception Form
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Prescription Mail Order Form
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Direct Member Reimbursement
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Designation of Personal Representative
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Required Notices and Disclosures

Individual marketplace health plan Disclosures
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Notice of Women’s Health and Cancer Rights
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Cox HealthPlans Notice of Privacy Practices
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Rights and Protections Against Surprise Medical Bills
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Individual Health Plan EPO Policy
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Other Forms

Authorization for Release of Health Information (HIPAA)
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Coordination of Benefits
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Case Management Self-Referral Form
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Coronavirus (COVID‐19) Forms

COVID‐19 Over‐the‐Counter Test Reimbursement Form
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Maintenance Medications List

Maintenance Medications
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