Additional Forms and Documents

Appointment of Representative Form

Our members can appoint a caregiver to act on their behalf. To do so, we must have written authorization signed by both the caregiver and the member.

A representative who is appointed by the court or who is acting in accordance with state law may also file a request on your behalf after sending us the legal representative document. You will not need to complete an Appointment of Representative Form if you provide another legal representation document with your request.

Download an Appointment of Representative form. Once the form is filled out in its entirety fax it to the Customer Service at 1-866-245-4120.

Exception and Prior Authorization Forms

Request a Formulary Exception or Prior Authorization

Print Exception and Prior Authorization forms, or use our easy Drug Search tool to find the forms you need.

Learn more about Exceptions and Prior Authorizations.

Request for a Medicare Prescription Drug Coverage Determination Form

You, an appointed representative, or your prescribing physician may use this form to request a coverage determination from the plan.

Learn more about Exceptions and Prior Authorizations.

2010 Change Notice Form

Current TexanPlus HMO members can use this change form to change their enrollment election to a different TexanPlus plan, change their premium payment option or to update contact information.

Direct Claims Form

Use this form to request reimbursement for your out-of-pocket drug costs.

Vaccine and Administation (Injection) Claim Form

Use this form to request for reimbursement of your covered Part D vaccines and their administration (injection) fees.