Frequently Requested Forms

EHP Total Care Health Visit Report

Please complete this form if you received a letter from EHP saying to do so in order to qualify for the voluntary Healthy Choice Rebate Program. This form is to be completed by a licensed health professional (MD, DO, NP, PA).

Download the EHP Total Care Health Visit Report by clicking here.

Mutual Health Services (formerly Antares) Claims Form
In some circumstances you may be required to pay up front for medical services. For example, if you are traveling outside the country, you may be required to pay for medical services with a credit card or cash. If you should pay up front for a medical service, a manual claim form can be submitted to Mutual Health Services along with the invoice from the provider of service.

Download the Claim form by clicking here

Coordination of Benefits (COB)
Coordination of Benefits (COB) is the procedure used to pay healthcare expenses when you or an eligible dependent is covered by more than one health plan. The COB procedure follows the rules established by the laws of the state of Ohio.

Download the Coordination of Benefits form by clicking here

Prior Authorization/Formulary Exception
Prior authorization is necessary for coverage of certain medications. These medications are listed in the Cleveland Clinic EHP Drug Formulary Book that was inserted in the Cleveland Clinic Summary Plan Description (SPD). The medications on the list may change during the year due to new drugs being approved by the FDA or new indications are established for previously approved drugs. A Prior Authorization/Formulary Exception Form must be completed or sufficient documentation must be submitted before a case will be reviewed.

All requests must meet the clinical criteria approved by the Pharmacy and Therapeutics (P&T) Committee before approval is granted. In some cases, approvals will be given a limited authorization date. If a limited authorization is given both the member and the physician will receive documentation on when this authorization will expire. Most requests will be processed within 1-2 business days from the time of receipt. A response will be faxed to the requesting physician, and the member will be informed of the request and the decision via mail.

Download the Prior Authorization/Formulary Exception Form by clicking here

Prescription Drug Benefit

The Cleveland Clinic Employee Health Plan (EHP) Prescription Drug Benefit is administered through CVS Caremark. CVS Caremark is one of the nation’s leading independent Prescription Benefit Managers (PBM). Years of experience and data from CVS Caremark’s extensive medical records database have shown that appropriate and cost-effective use of pharmaceutical therapies can be the key to a successful strategy for improving individual patient outcomes and containing overall healthcare costs. Prior authorization requirements are administered through Cleveland Health Network (CHN). Through your Cleveland Clinic EHP Prescription Drug Benefit, you have three options for filling your prescription medications The three options, described below, include the Cleveland Clinic Pharmacies, the CVS Caremark retail pharmacy network, and the CVS Caremark mail service program.

Download the Cleveland Clinic EHP Total Care Drug Formulary Book by clicking here

Cleveland Clinic Pharmacies Enhanced Benefit
Cleveland Clinic EHP members have the option of paying a lower percentage co-payment for their prescriptions by using one of the following Cleveland Clinic Pharmacies.

Cleveland Clinic Pharmacies — Locations and Hours of Operation

In addition, employees may request up to a 90 day supply of medication and have access to a pharmacy hotline for questions and pharmacist consultation services.

Download the Cleveland Clinic EHP Total Care Home Delivery Service: Processing Form by clicking here

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