Below is a listing of plan forms, brochures and documents to help you manage and understand your benefits.

Member Forms & Documents

Title Download
Official Plan Brochure – 2021 PDF
Summary of Benefits – 2021 PDF
2021 RCBP Medicare Brochure PDF
Prescription Drug Guide/Formulary PDF
Prescription Drug Guide – Specialty Drugs PDF
Prescription Drug Guide – All Other Drugs PDF
Specialty Quantity Limit Program – Drug List PDF
Performance Drug List PDF
Performance Drug List Change Summary PDF
Claim Form – Medical PDF
Claim Form – Mail Order Prescription PDF
Claim Form – Prescription, Retail Pharmacy PDF
Claim Form – Wellness Incentive PDF
Provider Nomination Form PDF
Authorization for Release of Protected Health Information (PHI) PDF