Member Forms & Documents

Member Forms & Documents - General

• 2021 Summary of Benefits and Coverage (PDF)
• Summary Plan Description (PDF)
• Sample ID Card - Active (PDF)
• Sample ID Card - Retiree (PDF)
• PCP Change Form (PDF)
• PHI Disclosure Form (PDF)
• Request for Medical Reimbursement (PDF)
• ID Card Request (PDF)
• Coordination of Benefits Questionnaire (PDF)

  Complete this form and return to HealthEdge Administrators if you or any of your dependents have other medical insurance.

• No Surprises Act Notice (PDF)

Member Forms & Documents - Pharmacy

• WellDyneRX Universal Formulary (PDF)

  A list of the most commonly-prescribed drugs covered by the Plan. Medications listed in all CAPS are considered Brand.

• WellDyneRX Prior Authorization List (PDF)
• WellDyneRX Specialty Medication List (PDF)
• WellDyneRX Claim for Reimbursement Form (PDF)
• Kern Medical Desk Delivery Consent Form (PDF)

Provider Forms & Documents