Forms for Employees of the Enrollees of Participating Employers (PE) Agencies

Format Options

Empire Plan Claims Forms and Non-Participating Provider Claim Forms and Administrative Forms

(These claim forms can also be obtained from your Agency Health Benefits Administrator)

Empire Plan Health Insurance Claim Form for Inside New York State
Download and photocopy as needed

Empire Plan Health Insurance Claim Form for Outside New York State
Download and photocopy as needed

Empire Plan
Non-Participating Provider Claim Forms

Order from:
UnitedHealthcare Service Corp.
P.O. Box 1600
Kingston, NY 12402-1600
1-877-769-7447 (Toll-Free)

Empire Plan
Prescription Drug Claim Forms

Please retain a photocopy of all submitted forms. All correspondence should include the enrollee's name, address, phone number and Identification Number printed on the enrollee's NYSHIP Empire Plan Benefit Card.

Download and photocopy the Enrollee Claim Submittal Form (Pharmacy Reimbursement Claim Form)
mailed completed form to:
The Empire Plan Prescription Drug Program
c/o Medco
P.O. Box 14711
Lexington, KY 40512

Mail general correspondence and questions regarding Plan design, the Empire Plan Preferred Drug List, and eligibility to:
The Empire Plan Prescription Drug Program
UnitedHealth Care
P.O. Box 5900
Kingston, NY 12402-5900

Mail Prior Authorization appeals to:
Medco
8111 Royal Ridge Parkway
Irving, Tx 75063

Download as needed and submit as directed on the form: Medicare Part D Secondary Claim Form

If your doctor feels it is necessary for you or your family member to have a brand-name drug (that has a generic equivalent), you can appeal the Mandatory Substitution Requirement. Call 1-877-7-NYSHIP (1-877-769-7447) 24 hours a day, seven days a week. For The Empire Plan Prescription Drug Program, press or say 4. Callers who use a Teletype writer (TTY) device may call toll free at 1-800-759-1089.

Empire Plan
Prescription Drug Mail Service Order Form

Download and photocopy Medco Parmacy Mail-Order Form as needed
Health, Allergy and Medication Questionnaire (to be completed and mailed with each NEW prescription)
Mail prescriptions and questionnaire to:
Medco
P.O. Box 6500
Cincinnati, OH 45201-6500

OptumHealth Behavioral Solutions
Mental Health and Substance Abuse Program

Claims and general correspondence:
OptumHealth Behavioral Solutions
P.O. Box 5190
Kingston, NY 12402-5190
1-877-769-7447 (Toll Free)

Mental Health and Substance Abuse Claim Form for Inside New York State
Download and photocopy as needed

Mental Health and Substance Abuse Claim Form for Outside New York State
Download and photocopy as needed

Appeals:
Optum
P.O. Box 1590
Kingston, NY 12402-5190

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Health, Dental and Vision Forms

PS 404pe (1/7/07) Participating Employer (PE) Health Insurance Transaction Form

PS 404i (1/7/07) NYS Health Insurance Transaction Form (PS-404 Instructions) [PDF]

PS 405 (5/09) Sick Leave Credit Election (Dual Annuitant) [PDF]

PS 406.2 (12/06) Deferred Health Insurance for Retirees (Indefinitely) [PDF]

PS 410 (9/09)(W) State Sick Leave Credit Preservation [PDF]

PS 425 (5/11) Domestic Partner Series

PS 431 (03/06) Health Insurance and Dental/Vision Insurance for Employees on Leave Without Pay [PDF]

PS 451 (4/10) Statement of Disability

PS 452 (8/06L) Application for Waiver of Premium [PDF]

PS 452I (8/06L) Instructions for the Application for Waiver of Premium [PDF]

PS 457 (1/11) Statement of Dependence [PDF]

PS 483.2 (5/06) Estimating Your Sick Leave Credit [PDF]

PS 548 (3/07) New Employee Benefits Checklist [PDF]

PS 548-I (3/07) New Employee Benefits Checklist Instructions [PDF]

PS 850 (7/07) Change of Address Form (for NY Active Enrollees and for NY and PE Retirees)

Young Adult Option Forms

For additional forms, contact your Agency Health Benefits Administrator.