Attention members, to find Healthcare Policy Forms, visit https://carecompass.ct.gov 
Select ‘State Employee’ (or ‘State Retiree’)
Select ‘Forms’

We are sharing forms commonly accessed in that portal.

WAIVERS

• CO-1315, rev 6/2023 - Emergency Room Copayment Waiver Request - Permalink
• CO-1331, rev 6/2023 - Lab Coinsurance Site of Service Waiver Request - Permalink
• CO-819; rev 08/2023 - Group Life Insurance Disability Premium Payment Waiver Application - Permalink
• Pru-01, rev 4/2023 - Prudent Rx Opt-out - Permalink
• CO-1316; rev 03/2024 - Health Enhancement Program Opt-Out - Permalink

GUARDIANSHIP

• CO-1321, rev 1/2023 - Annual Guardianship Certification Qualified Dependent - Permalink
• CO-1318, rev 5/2023 - Legal Guardianship Notification and Dependency Verification - Permalink
• CO-1048NQ, rev 1/2023 - Non-Qualified Child (Former Ward) Guardianship Enrollment Application - Permalink

PHARMACY

• CVS Pharmacy, rev 5/2017 - Coverage Exception Request - Permalink
• CVS Pharmacy, rev 10/2017 - CVS Caremark Mail Service Order Form - Permalink
• CVS Pharmacy, rev 10/2017 - Formulary Exception Prior Auth Request - Permalink
• CVS Pharmacy, rev 5/2023 - Mandatory Mail Exemption Request Form - Permalink

RETIREE HEALTH

• CO-1082, rev 12/2019 - Retiree/Annuitant Address Change - Permalink
• CO-744, rev 10/2023 - Retirees – Choice of Health Benefits After Retirement - Permalink
• CO-744OE, rev 10/2023 - Retirees – Open Enrollment Choice of Health Benefits After Retirement - Permalink

RETIREE HEALTH FUND

• CO-1305, rev 01/2021 - Rehired Employee’s Waiver Of Right To Restore Prior Service Credit For Retiree Healthcare Eligibility - Permalink
• CO-1303, rev 8/2023 - Retiree Health Fund – Affidavit - Permalink
• CO-1301, rev 8/2023 - Retiree Health Fund – Application for Contributions Refund - Permalink
• CO-1323, rev 8/2023 - Retiree Health Fund – Contribution Adjunct Faculty – Payment Adjustment - Permalink
• CO-1304, rev 8/2023 - Retiree Health Fund – Exemption Application and Waiver - Permalink
• CO-638, rev 8/2015 - Retiree Health Fund – Notice of Death – State Employee ( PDF | RTF ) - Permalink
• CO-1328, rev 08/2023 - Retiree Health Fund – Payment Adjustment - Permalink
• CO-1302, rev 8/2023 - Retiree Health Fund – Repayment of Retiree Health Fund for Prior Service Credit - Permalink