Select from the forms below (each form opens in a new browser window).
- Aetna Global Benefits Claim Form
This form should be completed when you have paid for services and need to request reimbursement. When seeking care in the US, Aetna Network providers will generally submit your claims directly to Aetna Global Benefits eliminating the need for you to do so. Requests for reimbursement should be faxed or mailed to the address(es) shown on the form.
- Anthem Blue Cross Claim Form
This form should be completed if you utilize providers not in the Anthem Blue Cross network. Network providers generally submit your claims directly to Anthem. Please call the Anthem Blue Cross customer service number listed on your Member ID card for the claims office address. Claims should be mailed to the Blue Cross and/or Blue Shield Plan of the state in which services were received.
- Anthem Disabled Dependent Certification Form
This form should be submitted to Anthem Blue Cross to certify eligibility for a disabled dependent child. Generally, unmarried disabled dependents who are biological children, adopted children, stepchildren, foster children or children for whom you are legal guardian may be covered under the Northrop Grumman Health Plan, regardless of age or student status, if the disability occurred before age 26, or age 19 (age 25 if a full-time student) if the disability began prior to 1/1/11. Please see summary plan description or contact the Northrop Grumman Benefits Center for more details.
- Anthem Blue Cross Transition Assistance Form
New enrollees in the Anthem EPO may apply for Transition Assistance. If your doctor is not in the Anthem Blue Cross network and you are being treated for an acute medical or behavioral health condition, a serious chronic condition, terminal illness, pregnancy or surgery, Anthem will work with you to ensure you receive uninterrupted care until your treatment is complete.
- CONEXIS Flexible Spending Account (FSA) Forms
Use these forms if you are currently enrolled in either the Dependent Day Care or Health Care FSA to submit claims for reimbursement of eligible expenses for your 2012/2013 FSA, and/or to sign up for direct deposit of your FSA claims. Please be sure to attach the necessary documentation.
- Delta Dental Claim Form
This form needs to be completed only if you use a dentist who does not participate in the Delta Dental Network of Providers. Delta network providers will file the claim for you.
- Disability Claim Instructions
This brochure from Unum provides you with instructions for filing a claim for disability benefits.
- Evidence of Insurability (EOI) Form (Optional Life)
This form needs to be completed if you select Optional Life Insurance in excess of five times your annual base pay or $600,000, whichever is less. If you select Spouse Life Insurance in excess of $50,000, you also must complete this form.
- Express Scripts Claim Form
This form needs to be completed any time you use a pharmacy that does not participate in the Express Scripts Network or if your in-network pharmancy claim was not be submitted electronically.
- Express Scripts Home Delivery Prescription Order Form
Visit the Express Scripts website and sign in with your Express Scripts user name and password. You can then download the form used to order prescription drugs through the Express Scripts Home Delivery Program.
- Express Scripts Proof of Benefits Form
If you have not received your ID card, please present this letter to your Express Scripts network pharmacist, to accurately process your prescriptions.
- HIPAA Authorization Form
This form allows you to give authorization to Use and/or disclose personal health plan information.
- HMO/EPO Primary Care Physician (PCP) Designation Form (for under age 65 retirees only)
This form is used to select a primary care physician if you and/or your dependent(s) are enrolled in an HMO/EPO.
- MetLife Special Needs Planning flyer
This flyer contains information about the MetLife Center for Special Needs Planning. This Center assists families who have dependents with special needs, by providing help with the legal and financial complexities associated with special needs planning.
- Primary Dental Care/CIGNA
CIGNA network providers must file the claim for you (no form available).
- Special Notice about Medicare Prescription Drug Choices
This notice applies to you and/or your covered family members who are eligible for Medicare.
- Tricare Supplement Claim Form
This form should be completed if your provider does not file for the balances which remain after Tricare has made their payment. Mail your completed claim to the address shown on the form and include copies of all applicable bills, Tricare Explanations of Benefits, and receipts from the provider for paid copay amounts.
- VSP Claim Form
This form needs to be completed only if you use a provider who does not participate in the VSP network. VSP providers will file the claim for you.