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Medical Claims Forms

Medical Claim Form
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Authorization/Precertification Form
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Prescription Forms

Direct Member Reimbursement
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Prescription Prior Authorization
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Quantity Limit Exception Request
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Prescription Non Formulary Exception Form (NFE)
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Designation of Personal Representative
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Prescription Mail Order Form
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Prescription Claim for Compound Medications
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Other Forms

Authorization for Release of Health Information (HIPAA)
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Coordination of Benefits
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View Our 2025 Individual Marketplace Products

Plan Brochure
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Plan Overview
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Cox HealthPlans Bronze Preferred (Off Exchange) $9,200 Deductible
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Cox HealthPlans Bronze Preferred (On Exchange) $9,200 Deductible
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Cox HealthPlans Bronze Preferred (American Indian) $0 Deductible
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Cox HealthPlans Bronze Preferred (Limited Cost Sharing) $9,200 Deductible
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Cox HealthPlans Bronze Expanded Standard (Off Exchange) $7,500 Deductible
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Cox HealthPlans Bronze Expanded Standard (On Exchange) $7,500 Deductible
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Cox HealthPlans Bronze Expanded Standard (American Indian) $0 Deductible
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Cox HealthPlans Bronze Expanded Standard (Limited Cost Sharing) $7,500 Deductible
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Cox HealthPlans Silver Connect 9 (Off Exchange) $6,000 Deductible
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Cox HealthPlans Silver Connect 9 (On Exchange) $6,000 Deductible
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Cox HealthPlans Silver Connect 9.2 (American Indian) $0 Deductible
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Cox HealthPlans Silver Connect 9.3 (Limited Cost Sharing) $6,000 Deductible
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Cox HealthPlans Silver Connect 9.4 (73% CSR) $5,000 Deductible
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Cox HealthPlans Silver Connect 9.5 (87% CSR) $1,300 Deductible
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Cox HealthPlans Silver Connect 9.6 (94% CSR) $200 Deductible
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Cox HealthPlans Silver Preferred (Off Exchange) $3,500 Deductible
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Cox HealthPlans Silver Preferred (On Exchange) $3,500 Deductible
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Cox HealthPlans Silver Preferred (American Indian) $0 Deductible
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Cox HealthPlans Silver Preferred (Limited Cost Sharing) $3,500 Deductible
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Cox HealthPlans Silver Preferred (73% CSR) $3,500 Deductible
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Cox HealthPlans Silver Preferred (87% CSR) $500 Deductible
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Cox HealthPlans Silver Preferred (94% CSR) $0 Deductible
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Cox HealthPlans Silver Standard (Off Exchange) $5,000 Deductible
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Cox HealthPlans Silver Standard (On Exchange) $5,000 Deductible
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Cox HealthPlans Silver Standard (American Indian) $0 Deductible
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Cox HealthPlans Silver Standard (Limited Cost Sharing) $5,000 Deductible
Download PDF
Cox HealthPlans Silver Standard (73% CSR) $3,000 Deductible
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Cox HealthPlans Silver Standard (87% CSR) $500 Deductible
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Cox HealthPlans Silver Standard (94% CSR) $0 Deductible
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Cox HealthPlans Gold Preferred (Off Exchange) $500 Deductible
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Cox HealthPlans Gold Preferred (On Exchange) $500 Deductible
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Cox HealthPlans Gold Preferred (American Indian) $0 Deductible
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Cox HealthPlans Gold Preferred (Limited Cost Sharing) $500 Deductible
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Cox HealthPlans Gold Standard (Off Exchange) $1,500 Deductible
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Cox HealthPlans Gold Standard (On Exchange) $1,500 Deductible
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Cox HealthPlans Gold Standard (American Indian) $0 Deductible
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Cox HealthPlans Gold Standard (Limited Cost Sharing) $1,500 Deductible
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