Health Forms & Documents

Health Plan Forms

• Wellness Rewards Reimbursement Form

• Member’s Designation of a Personal Representative

• Health Care Proxy Form

Prescription Drug Plan Forms

• CVS/Caremark Mail Order Enrollment Form

• CVS/Caremark Prescription Reimbursement Claim Form

More Forms (Enrollment, Termination, etc.)

• Continuation of Coverage Election Form (eff. 7/1/2023)

• Main Forms & Documents Page

Health Plan Documents

• Enhanced Blue Cross PPO Plan Summary of Benefits & Coverage (SBC)
  English | Spanish | Portuguese

• Basic Blue Cross PPO Plan Summary of Benefits & Coverage (SBC)
  English | Spanish | Portuguese

• High Deductible Health Plan Summary of Benefits & Coverage (SBC)
  English | Spanish | Portuguese

• Enhanced Blue Cross PPO Plan Medicare Primary Payer Participant - Summary of Benefits & Coverage (SBC)

• Basic Blue Cross PPO Plan Medicare Primary Payer Participant - Summary of Benefits & Coverage (SBC)

• Section 125 Cafeteria Plan Summary

• FAQs for Employees Receiving 1095-C Forms

• Disclosure: RCAB Wellness Program Reasonable Accommodation/Reasonable Alternative Availability

• Prescription Benefit Summary – Enhanced Plan

• Prescription Benefit Summary – Basic Plan

• CVS/Caremark Mail Service Pharmacy 

• Getting Started with CVS Caremark Mail Service

• RCAB CVS Caremark Maintenance Choice FAQs

• No Surprises Act Notice

• CHIP Notice

• HIPAA Privacy Notice

• Medicare Part D Notice

• ACA Marketplace Exchange Notice

• Additional Health Plan Notices