Forms
Below are some useful resources and forms for each of the plan options.
2026 Plan Documents
2025 Plan Documents
2026 Medicare Rx (PDP) Documents
- PSHBP Medicare Rx 2 Summary of Benefits (PDF)
- PSHBP Medicare Rx 4 Summary of Benefits (PDF)
- 2026 Medicare Rx Evidence of Coverage (PDF)
- 2026 Annual Notice of Change (PDF)
English | Spanish
2025 Medicare Rx (PDP) Documents
Plan Forms
- Coordination of Benefits (PDF)
- HSA/HRA Selection Form (PDF)
- Medical Claim Form (PDF)
- Prescription Mail Order Form (PDF)
- Prescription Reimbursement Claim Form (PDF)
- Social Security Number Submission Form (PDF)
- Vision Claim Form - Davis (PDF)
- International Claim Form (PDF)
(for members receiving care outside of the U.S.)