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Additional Resources
Member Resources
Reference
Labor Relations
Retirement
Benefits
PAC
Meetings & Agenda
Untitled Document
> Retiree Plan Rates
> HMO Retiree Enrollment Instructions
> HMO High Schedule of Benefits
> HMO Low Schedule of Benefits
> HMO Rx List -
www.pacificare.com
> Mental Health Schedule of Benefits
(Non-Severe Mental Health Rider for HMO High and Low)
> HMO Low Rx Co-Pay List
> HMO High Rx Co-Pay List
Forms
> HMO Enrollment Form
(New enrollment only)
> HMO Enrollment Change Form
(Current enrollee changes: add / delete and contact information)
> Pacificare RX Mail Order Form
> Pacificare HMO Continuity of Care Form
(If currently under Dr. care for sever/chronic illness or third trimester pregnancy)
> HMO Prior Authorization Form
> Back to Medical Benefits Home Page
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