Forms & Documents

Complete this form if someone covered by your plan has suffered an injury that was, or may have been, caused by another person.

A document containing information about your COBRA continuation coverage rights.

Complete this form to designate an address other than the participant address that will be used for all explanation of benefits statements, correspondence, and claim checks.

Complete these forms to designate an address other than the participant address that will be used for all explanation of benefits statements, correspondence, and claim checks and to restrict the use and disclosure of your protected health information or protected health information of your minor child or to add a password of your choosing.

Use this form to notify TeamCare if any other insurance coverage exists for an adult child.

This document contains a list of non-specialty medications, organized by drug class, that are covered or excluded by your plan’s formulary.

This document contains a list of specialty medications, organized by drug class, that are covered or excluded by your plan’s formulary.

Use this form to order new prescriptions, or order refills, through the CVS Caremark™ Mail Order Pharmacy.

NATA65P qualifying pensioners should use this form to request reimbursement for prescriptions under the NATA65P/Medicare Part D benefit.

Members covered by active or retiree plans should use this form to request reimbursement for prescription claims paid out-of-pocket, or for Coordination of Benefit prescription claims.

A list of national pharmacy chains that are a part of the CVS Caremark TeamCare Rx Retail Program.

Use this form to notify TeamCare of a short-term disability due to a non-work-related injury or illness or inability to work due to pregnancy.

Complete this form to notify TeamCare of a continued period of disability.

Use this form to apply for an extension of health coverage for your disabling condition. 

Complete this form to postpone Retiree Health Plan coverage to a later date, if you have other insurance coverage in effect.

Complete this form to reinstate your Retiree Health Plan benefits if you have previously postponed coverage.

Use this form to request Retiree Health Plan coverage for your new spouse.

View this document to help determine if you are eligible or remain eligible for the Retiree Health Plan.

This form should be completed by a surviving beneficiary or executor of a member’s estate to claim the TeamCare life insurance benefit when the deceased participant did not designate a beneficiary.

Complete this form in the event of accidental dismemberment from a bodily injury.

Use this form to apply for death and accidental death benefits.

Complete this form to choose a beneficiary for your TeamCare Life Insurance Benefit.

Use this form to apply for total and permanent disability/waiver of premium benefits.

This document describes how medical information about you may be used and disclosed, and how you can access this information.

Complete this form to authorize the use and disclosure of your protected health information or the protected health information of your minor child.

Complete this form to restrict the use and disclosure of your protected health information or the protected health information of your minor child or to designate a password of your choosing.

Complete this form to designate an address other than the participant address that will be used for all explanation of benefits statements, correspondence, and claim checks.

Complete these forms to designate an address other than the participant address that will be used for all explanation of benefits statements, correspondence, and claim checks and to restrict the use and disclosure of your protected health information or protected health information of your minor child or to add a password of your choosing.

Complete this form to request a copy of your or protected health and welfare information or the protected health information of your minor child.

Use these links to access the Summary Annual Reports for active and retiree plans.

Use these links to access the Summary Annual Reports for active and retiree plans.