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If you need assistance completing any forms or have any questions, please call EssentialCare’s toll-free Customer Service Line, 1-866-740-4006, Monday through Friday, 8:30 a.m. to 8:00 p.m. Eastern Time. A translation line is available for most languages.

Authorized Representative Form / Formulario de Representante Autorizado

EyeMed Out-of-Network Claim Form

Medical Claim Form / Formulario de Reclamo de Gastos Médicos

Missed Premium Direct Payment Form

Prescription Drug Claim Form (Use this form if RxGRP: DISCOUNT is on your ID card.)

Prescription Drug Claim Form - (Use this form if RxGRP: BXPAI is on your ID card.) If your Medical plan entitles you to pay a co-pay at the point of purchase and your prescription was not filed directly to OptumRx by the pharmacy, use this form to submit for payment.
If your Medical plan entitles you to a discount at the point of purchase, and you file your receipts to PAI for reimbursement, please use the Medical Claim Form above.
Please see your Summary Plan Description if you have questions as to which plan is associated with your group.

Short-Term Disability / Proof of Loss Claim Form

Term Life / Accidental Death Claim Form

Termination / Involuntary Loss of Coverage Form


Discount program


HIPAA-all groups