
Aetna Website
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Member Services: (888)702-3862 or (888)802-3862
Forms:
Member Application
HIPAA Form
Medical Claim Form
Dental Claim Form
Mail Order Rx Form
Links:
Provider Search
Formulary
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Member Services: (800)521-3535
Claims Services: (800)348-4489
Claims Fax: (866)424-8482
Forms:
HIPAA Authorization Form
Policyholder Change & Service Request
Critical Illness Claim Form
Group Voluntary STD/LTD/Waiver of Premium Claims
Cancer/Specified Disease/ICU/Heart/Stroke Claims
Hospital Indemnity Claim
Wellness Claims
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Member Services: (888)868-FLEX (3539)
Member Services Email: service@flex125.com
Forms:
Enrollment Form
Claim Form
Direct Deposit Form
Employee Request for Service Form
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Member Services HMO/POS: (866)681-7373
Links:
Find a Provider
Rx Information
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Member Policy Services: (800)733-7879
Forms:
Member Application
Member Change Form
Dental Claim Form
STD Claim Form
LTD Claim Form
HIPAA Authorization Form
Links:
Provider Search
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Customer Service: (508)809-6010
Email: info@brokersuite.com
Links:
MyBenefitsCount Information
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Member Services: (866)686-2242 Prescription Drug: Express Scripts (800)585-5794
Forms:
Member Change/Enrollment Form
Plus Billing Form
HIPAA Member Authorization Form
Waiver of Coverage
Links:
Provider Search
Express Scripts
Formulary
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Davis Vision Website
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Member Services: (800)999-5431
Links:
Provider Search
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Delta Dental Website
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Member Services: (877)472-2669
Enrollment Fax: (415)874-3960
Forms:
Member Enrollment/Change Form
Links:
Provider Search
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Geisinger Health Plan Website
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Member Services Referral Plan: (800)447-4000
Member Services Non-Referral Plan: (800) 504-0443
Forms:
Member Enrollment Form
Member Change Form
Links:
Provider Search
Rx Formulary Information
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Member Services: (800)685-4542
Forms:
Dental Claim Form
STD Claim Form
LTD Claim Form
Physician Statement
Links:
Provider Search
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Member Services: (800)523-2233
Enrollment Changes/Term Fax: (888)701-8234
Forms:
Enrollment Form
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Member Services: (800)788-8445
Forms:
Member Enrollment/Change Form
Employee Termination Form
Rx Claim Form
Links:
Provider Search
Formulary
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Customer Service: (800)345-3806 Merck MEDCO: (800)903-6228 Fax Number for Adds, Terms & Changes: (717)302-2985
Forms:
Member Change Form
Waiver of Coverage
Links:
Provider Search
Formulary
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Member Services PPO: (800)626-8144 Member Services HMO: (800)227-3114 Member Services POS: (800)253-3854
Forms:
Member Change Form
Waiver of Coverage
HIPAA Authorization
Rx Mail Order Form
Rx Claim Form
Keystone Transmittal Form
Links:
Provider Search
Formulary
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Member Services: (800)492-2385
Links:
Member Website
Provider Search
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Member Services: (800)423-2765
Enrollment Changes Fax: (877)573-6177
Disability Claims Fax: (877)843-3950
Forms:
Member Enrollment Form
Beneficiary Change Form
Dental Claim Form
LTD Claim Form
STD Claim Form
Links:
Provider Search
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Member Services: (800)ASK-4-MET (275-4638)
Enrollment Info Fax: (888)505-7446
Forms:
Enrollment Form (all coverages)
Dental Claim Form
Change Request Form
Beneficiary Designation Form
Links:
Provider Search
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Dental Member Services: (877)999-2330
Disability Claims: (800)877-5176
Forms:
Employee Termination Report Form
Beneficiary Designation
Dental Claim Form
Disability Claim Form
Links:
Provider Search
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Member Services: (800)537-4565
Forms:
Member Enrollment Form
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Member Services: (800)247-4695
Rx Caremark: (877)683-6838
Fax: (866)785-
Forms:
Member Enrollment Form
Member Change Form
Group Enrollment Change Form
HIPAA Authorization Form
Rx Formulary
Links:
Provider Search
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Member Services: (800)638-3120
Links:
Provider Search
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Member Services: (800)247-6875
Forms:
Member Enrollment Form
Dental Claim Form
Vision Claim Form
List Bill Change Form
Links:
Provider Search
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Member Services Group Life: (800)628-8600
Member Services Group LTD: (800)368-1135
Member Services Group STD: (800)368-2859
Member Services Group Dental: (800)547-9515
Forms:
Dental Claim Form
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Member Services: 1-800-332-0366 (PPO)/ 1-866-357-3304 (DHMO)
Forms:
Member Application/ Change Form
Member Claim Form
DHMO Change Form
DHMO Referral Claim Form
Links:
Provider Search
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Member Services: 1-800-357-0978 Fax Adds & Terms: 1-813-818-3724
Forms:
Member Enrollment Form (2-50)
Member Enrollment Form (51-99)
Member Claim Form
Rx Claim Form
Claims Submit Address
Links:
Provider Search
Formulary
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Member Services: (800)877-7195
Links:
Provider Search
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