Forms/Documents

Skip to content

Health Care

Medical

Aetna Medical Claim Form

CVS Caremark Prescription Drug Mail Service Order Form (MAPD Plan)

CVS Caremark Prescription Drug Home Delivery Form

Express Scripts Claim Form

Dental

Aetna Dental Claim Form

Vital Savings by Aetna Enrollment Form

Health Care
Medical	Aetna Teladoc Services Express Scripts Getting Started with Home Delivery Express Scripts Preferred Drug/Exclusion List Express Scripts Preventive Drug List Oxy Medicare Advantage PPO Plan Summary Oxy Retiree Medical Plan Summary Aetna Retiree Dental PPO Summary Western New York Medical Plan Overview Transparency in Coverage Rule – Machine Readable Files
Spending Accounts
Flexible Spending Accounts Health Care FSA Dependent Care FSA Limited Purpose FSA	PayFlex Reimbursement Accounts Claim Filing Guidelines
Other
	Retiree Source Newsletter

Health Care
Medical	Oxy Medicare Advantage PPO Plan for INDSPEC - Annual Notice of Change Oxy Medicare Advantage PPO Plan for INDSPEC - Evidence and Statement of Coverages Oxy Medicare Advantage PPO Plan for Pre-1984 - Annual Notice of Change Oxy Medicare Advantage PPO Plan for Pre-1984 - Evidence and Statement of Coverages Oxy Medicare Advantage PPO Plan for General - Annual Notice of Changes Oxy Medicare Advantage PPO Plan for General - Evidence and Statement of Coverages Summary of Benefits and Coverage Oxy LAPC Retiree HDHP Pre-65 Oxy Retiree Non-Medicare Medical Plan SBC BCBS of Michigan - OCC Div. 0027 SBC BCBS of Michigan - OCC Div. 0028 SBC BCBSTX - PPO INDSPEC Plan SBC BCBSTX - PPO Pottstown 15 SBC BCBSTX - PPO Pottstown 5 SBC Oxy BCBSTX HDHP Medical Plan SBC Oxy BCBSTX PPO Medical Plan SBC Summary Plan Descriptions Express Scripts Prescription Drug SPD Oxy Medicare Advantage PPO Plan SPD Oxy Retiree Non-Medicare Eligible Medical SPD
Legacy Anadarko Retiree Medical	Summary Plan Descriptions: Legacy APC Retiree Health Benefits Plan HRA SPD Legacy APC Retiree Health Plan Group SPD
Dental	Summary Plan Descriptions Retiree Dental SPD
Other
	OCC: Creditable Represented Notice OCC: Non-Creditable Represented Notice OPC: Creditable Non-Represented Notice Required Federal Notices, Retiree (no grdftr.) Required Federal Notices, Retiree (with grdftr.) HIPAA Privacy Notice HIPAA Special Enrollment Notice USERRA Notice WHCRA Notice Summary Annual Reports: 001 OPC Savings SAR 060 OPC Retirement SAR 591 OPC Welfare Plan SAR 651 OPC Retiree Medical SAR 653 OPC Oxy Medicare Advantage PPO Plan SAR 502 INDSPEC Group Insurance SAR 503 OCC BCBS Hourly Employee Niagara SAR 504 OCC LTD SAR 511 OCC BCBS for Hourly EE North Tonowanda 522 OCC Group Life 600 OCC Medical Plan 730 OCC Retiree Medical Plan 501 Anadarko Petroluem Corp Health Benefits Plan 502 Anadarko Petroluem Corp Ancillary Benefits Plan 504 Anadarko Petroluem Retiree Health Benefits Plan