Forms

Anthem Out-of-Network Claims Reimbursement
Beneficiary Designation
Eyemed Out-of-Network Provider Reimbursement
Prime Therapeutics Prescription Drug Claim Form
Oral Health Enhancement Option Due to Gum Disease Form
Oral Health Enhancement Option Due to Medical Condition Form

Updating Your Contact Information

Contact the Fund Office if you have a change in your home address, phone number, or email:

• contact@ufcwnewenglandhealthfund.com
• 860-470-8551
• 888-705-1092 (toll-free)
• UFCW New England Health Fund
  290 Post Road West
  P.O. Box 5160
  Westport, CT 06880-9917

Questions?

Contact the Fund Office for questions about benefits eligibility, enrollment, and coverage:

• contact@ufcwnewenglandhealthfund.com
• 860-470-8551
• 888-705-1092 (toll-free)