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.
- 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).
- Click here to access the Individual Enrollment/Change form for a 2018 policy
- Click here to access the Individual Enrollment/Change form for a 2017 policy
- 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 here for the 2017 list of preventive services for our Members
Click here for the 2018 list of preventive services for our Members
Sample Member Benefit Agreements
To assist potential members in understanding Community Health Options coverage, we provide sample Member Benefit Agreements for your review.
Please click on the plan below to view Summary of Benefits & Coverage for your plan.
Summary of Benefits & Coverage
2018 Individual Plans:
Maine Individual Plans
2018 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.