Forms & MRF Files

Claim Forms

Enrollment Forms

Open the enrollment form below, download it and save it to your computer.  Once saved, open that file, fill in all necessary fields, save the completed form again and attach and email it to the IDA Enrollment Department.

OptumRx Forms

Express Scripts Forms

ProAct Forms

Miscellaneous Forms

Regulatory Forms

Teladoc Forms

EmpiRx Forms

EmpiRX Group Specific Forms:

Cigna Forms & Programs

Frequently Used

All Others

CignaRx - Cigna Pharmacy Service Center                  

If a member fills a script and pays out-of-pocket while the eligibility is being loaded with Cigna, please have the member complete the below and return it along with a copy of their pharmacy receipt to the address on page 2 and a reimbursement will be issued.

  • Prescription Drug Claim Form - English

Aetna Programs                  

Brightline Behavior Health Program

LifeMart Wellness Discounts

Phoenix Rx PBM                 

Transparency In Coverage - Machine Readable Files

In-Network Files

Out-Of-Network Files

  • Reliant
  • Zelis

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