Documents and Forms

Community Health Options Drug Formulary
What is a Formulary?  A  Formulary is a list of drugs that a health insurance plan covers.  The Formulary is updated on a regular basis.
 
Forms 
  • Individual Enrollment/Change Form  - This form is for Maine residents with off exchange coverage who are enrolling for new coverage or need to update their plan information.  This form can also be used for qualifying life events to change existing coverage.  (Note: Members with on exchange coverage may not use this form and must make changes by contacting the Federally Facilitated Marketplace directly at 800‐318‐2596).
  • Cancellation Form - Maine - For Members seeking to discontinue their Community Health Options coverage.  Subscribers seeking to drop a dependent spouse or child from the policy must complete an Individual Enrollment/Change Form.  (Note: Members with on exchange coverage may not use this form and must make changes by contacting the Federally Facilitated Marketplace directly at 800-318-2596)
  • 10-Day Look Form – For Members seeking to discontinue their Community Health Options coverage during the “free look period” as described under the terms of the Member Benefit Agreement. Members signed up through the Federally-Facilitated Marketplace (Healthcare.gov) will have to request a termination through the Marketplace in addition to completing this form.
  • Medical Reimbursement Form - Use this form for any reimbursement requests you may have if your provider is not submitting your claim. 
  • Express Scripts Prescription Reimbursement Form - Use this claim form to request reimbursement for covered prescription expenses after 7/1/2016.
  • Member Appeal Form - Use this form if you disagree with a decision about your benefit, you may be able to file an appeal. 
  • Protected Health Information (PHI) Form - This form allows you to specify how much or how little private information you’re willing for us to disclose to the intended recipient.

Preventive Services Summary
Click List of preventive services for our Members to view.

Sample Member Benefit Agreements 
To assist potential members in understanding Community Health Options coverage, we provide sample Member Benefit Agreements for your review.
Summary of Benefits & Coverage
Please click on the plan below to view Summary of Benefits & Coverage for your plan.

2017 Individual Plans:

Maine Individual Plans
2017 Group Plans:

Maine Small Group Plans
Maine Large Group Plans  

If you're looking for past Summary of Benefits & Coverage and Sample Member Benefit Agreements you can find them below.