Click on the links below to download the forms you need.
2018 Prescription Claim Form
- Click here for a form to request reimbursement for out of pocket payment of prescription drugs
2018 Mail Order Prescription Form
- Click here to download the mail order prescription form
2018 Medical Claim Form
- Click here to download the medical claim form
Special Enrollment Period Validation List
2018 Member-Designated Representative Form
2018 Monthly Premium Withdrawal Form
2018 Change Form
2018 Appeal Form
Click here for an online form to file an appeal.
2017 Appeals
Mail ONLY 2017 appeals to:
Altius Health Plans
Appeals Dept.
PO Box 7147
London, KY 40742
Fax #: 801-323-6050
2017 Claims Forms
2017 Mail Medical Claim form to:
Mountain Health Coop
PO BOX 7147
London, KY 40742
2017 Rx Claims
Mail 2017 Rx Claim form to:
Express Scripts
P.O. Box 14236
Lexington, KY 40512