MENU Login Shop Plans Members Employers For Employers Group Plans Medical Mgmt Healthy Living Initiatives Provider Directory Network Map Resources & Forms Brokers Providers Prescription Info Virtual Visits FAQs Careers About Us News/Blog Contact Us Small Group Metal Plans Forms Employee Application - Metal Plans This form is used for enrolling a new employee, adding or terminating dependents, waiving coverage, address and name changes, and special enrollment in a small group metal plan. DOWNLOAD PDF Employer Application - Metal Plans This form is completed by a newly enrolled employer. It is also used for amendments to the small group metal plan group contract. DOWNLOAD PDF Continuation of Coverage (COBRA) This form is for an employer to notify Cox HealthPlans of a member’s election for COBRA coverage. DOWNLOAD PDF Retraction Notice This form is used to retract an application for enrollment and/or a termination to the health benefit plan. DOWNLOAD PDF Employee Termination This form is used to remove an employee from the group health plan. DOWNLOAD PDF EPO Plan Forms Employee Overview - EPO Network This is a benefits overview of the Exclusive Provider Organization (EPO) network for employees. Please note that this is not a comprehensive coverage list and is subject to change. Employees should contact Member Services to verify their individual benefits. DOWNLOAD PDF Employer Application - EPO This form is completed by a newly enrolled employer. It is also used for amendments to the EPO group contract. DOWNLOAD PDF Employee Application - EPO This form is used for enrolling a new employee, adding or terminating dependents, waiving coverage, address and name changes, and special enrollment in an EPO plan. DOWNLOAD PDF Retraction Notice This form is used to retract an application for enrollment and/or a termination to the health benefit plan. DOWNLOAD PDF PPO Plan Forms Continuation of Coverage (COBRA) This form is for an employer to notify Cox HealthPlans of a member’s election for COBRA coverage. DOWNLOAD PDF Employer Application - PPO This form is completed by a newly enrolled employer. It is also used for amendments to the PPO group contract. DOWNLOAD PDF Employee Application - PPO This form is used for enrolling a new employee, adding or terminating dependents, waiving coverage, address and name changes, and special enrollment in a PPO plan. DOWNLOAD PDF Employer Attestation HRA Form - Large Group This form is used to confirm that an HRA program will be in place in conjunction with an employer’s current health policy, and allow for validation of compliance with the Affordable Care Act plan requirements surrounding Maximum Out of Pocket limitations and Minimum Value. DOWNLOAD PDF Retraction Notice This form is used to retract an application for enrollment and/or a termination to the health benefit plan. DOWNLOAD PDF Employee Termination This form is used to remove an employee from the group health plan. DOWNLOAD PDF Level Solutions Plan Forms Continuation of Coverage (COBRA) This form is for an employer to notify Cox HealthPlans of a member’s election for COBRA coverage. DOWNLOAD PDF Retraction Notice This form is used to retract an application for enrollment and/or a termination to the health benefit plan. DOWNLOAD PDF Employee Termination This form is used to remove an employee from the group health plan. DOWNLOAD PDF Standard Stop Loss Disclosure Form This form is for an employer as part of the application for stop loss coverage. DOWNLOAD PDF Employee Application This form is used for enrolling a new employee, adding or terminating dependents, waiving coverage, address and name changes, and special enrollment in a Level Funded plan DOWNLOAD PDF Medical Claim Forms Medical Claim Form This form is used if a member needs to submit a medical claim. DOWNLOAD PDF Authorization/Precertification Form This form is used to request authorization of a medical service or procedure. DOWNLOAD PDF Prescription Forms Prescription Request Form Form that can be mailed to Elixir Pharmacy or faxed directly from physician office. DOWNLOAD PDF Prescription Claim Form This form is used if a member needs to submit a prescription claim. DOWNLOAD PDF Prescription Appeal Form This form is used for prescription appeals. DOWNLOAD PDF Quantity Limit Exception Request This form is used by a physician to request authorization for a quantity above the allowed limit on certain medications. DOWNLOAD PDF Prescription Mail Order Form This is the form used to request mail order service for prescription medications. DOWNLOAD PDF Formulary Prescription Exception Form Certain requests for coverage require review with the prescribing physician. DOWNLOAD PDF Designation of Personal Representative This form is used to designate those people allowed to receive information from Envision about your medical information and prescription claims. DOWNLOAD PDF Prescription Prior Authorization This form is used by a physician to request authorization of a particular prescription medication. DOWNLOAD PDF Prescription Non Formulary Exception Request DOWNLOAD PDF Direct Member Reimbursement Use this form to request reimbursement for claims that your pharmacy didn't process under your insurance. DOWNLOAD PDF Prescription Claim for Compound Medications This form is used if a member needs to submit a prescription claim for compounded medications. DOWNLOAD PDF Other Forms Coordination of Benefits This form is used to verify if you or your enrolled dependents have other insurance while insured with Cox HealthPlans. DOWNLOAD PDF Authorization for Release of Health Information This form is used to designate those people allowed to receive information about your policy. DOWNLOAD PDF Self-Referral - Case Management This form is used to request assistance from our Medical Management Team. DOWNLOAD PDF Direct Payment: PPO This form is used for group premium payments to be automatically deducted from your bank account. DOWNLOAD PDF Barracuda Encrypted Email Guide This document provides guidance on how to open a Barracuda encrypted email received from CoxHealthPlans. DOWNLOAD PDF First Health Information/Network Map This provides information regarding the Cox Health Plans Network, and access to First Health for nationwide PPO coverage DOWNLOAD PDF Missouri Certification of Employer Status (MCES) The Missouri Certification of Employer Status form (MCES) is used to assist Cox HealthPlans in determining group size for the purposes of renewal pricing. DOWNLOAD PDF Guidebooks Employer Online Bill Pay User Guide This document provides guidance for Plan Administrators on how to pay a group's premium online (available for groups beginning with CI and MG group numbers). DOWNLOAD PDF Helpful Links for Your Cox HealthPlans Membership CoxHealth Express CoxHealth patients, here’s your online tool to manage all aspects of your health. An Express account is secure, convenient and puts you in control. With an Express account, you can: view health records and lab results, communicate with your physician, pre-register for hospital procedures, schedule appointments (select locations), renew prescriptions, pay your bill, take a wellness assessment and more. MORE Save My Spot Spend less time waiting in line when you're feeling under the weather. With Save My Spot, simply choose your location and time, fill out a basic form, and wait from the comfort of your home. Once you arrive, check in at the front desk and you should be seen promptly by a member of the CoxHealth medical team. MORE Elixir Find all of your prescription drug information MORE First Health Directories and Provider Search Online Find First Health providers and the information you need if you need medical attention outside of our coverage area. You can also call First Health customer service at (800) 226-5116. MORE Right Care I Right Now When you can't wait for an appointment with your health care provider, we're here for you with virtual visits, walk-in clinics, urgent care and emergency care. Not sure what level of care you need? Review this chart to help you decide. If you're experiencing a life-threatening illness or emergency, please immediately go to the nearest emergency room or call 911. MORE 24/7 Urgent Care The need for health care doesn’t always arise during daytime hours. For times when illnesses and injuries should be addressed right away -- but aren’t severe enough for a trip to the emergency room care is available 24/7 at the Turner Center’s Urgent Care in Springfield. MORE Welcome & Access Clinics Access to health care just got easier: CoxHealth’s Welcome and Access Clinics, are a place where new patients can be seen until they’re established with a primary care provider. The clinics are a resource for that in-between time where patients can receive medication refills, and it’s open to anyone new to the CoxHealth system with chronic medical needs. Springfield Branson MORE We have representatives ready to help you with any question or concern you might have. Call our Marketing Department at (417) 269-4679 or toll free at (800) 664-1244 or email us at grouphealth@coxhealthplans.com. BACK TO TOP CONTACT US PHONE: 417.269.4679 PHONE: or 800.664.1244 FAX: 417.269.2949 MAILING ADDRESS Cox HealthPlans PO Box 5750 Springfield, MO 65801-5750 OR VISIT US AT Cox HealthPlans Medical Mile Plaza 3200 S. National, Building B Springfield, MO 65807 ©Cox HealthPlans LLC