Documents and Forms

The Annual Notice of Change details any changes in the plan’s costs, coverage, or service area that will take effect the following January.

Updated 11/19/24

The Evidence of Coverage provides the most detail about your health plan. This includes how the plan works, what’s covered, what’s not covered, the cost of services, which services require prior authorization, and much more.

Updated 10/1/24

The Summary of Benefits offers an overview of how you and your plan share the cost of covered healthcare services.

Updated 12/27/24

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The Annual Notice of Change details any changes in the plan’s costs, coverage, or service area that will take effect the following January.

Updated 10/1/25

The Summary of Benefits offers an overview of how you and your plan share the cost of covered healthcare services.

Updated 10/1/25

List of covered drugs

Updated 9/30/25

Prior authorization drug list

2025 prior authorization drug list

Updated 9/30/25

List of covered drugs

Updated 10/1/25

Prior authorization drug list

2026 prior authorization drug list (coming soon)

Updated 10/1/25

Member forms

Annual Health Survey
Appointment of Representative form
Assign or Revoke a Personal Representative form (updated 7/6/23) | Spanish
Auto pay form (updated 10/4/21)
Care Management PHI Authorization form (updated 5/28/25)
Release of Information form (updated 7/6/23) | Spanish
Release of Reproductive Healthcare Attestation form (updated 10/21/24)

Reimbursement forms

Medical reimbursement form (updated 3/4/25)
Northeast Delta Dental Reimbursement Form
Use this form if you need to be reimbursed for seeing an out-of-network Northeast Delta Dental provider. WellSense Signature Access (PPO) plan only.
OTC reimbursement form (updated 1/24/25)
Request reimbursement for eligible OTC and health-related items that you purchased at a participating retailer.
Prescription drug reimbursement form (updated 5/13/24) | Spanish
Vision debit card reimbursement form (updated 1/24/25)
Request reimbursement for vision services and hardware. WellSense Added Value and WellSense Choice plans only.
VSP reimbursement form (updated 1/24/25)
Use this form if you need to be reimbursed for seeing an out-of-network VSP provider. WellSense Signature Access (PPO) plan only.

Plan benefit documents

Pharmacy documents

Member forms

Other documents