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Members
Here is a list of commonly requested forms and documents for TeamstersCare members. Unless otherwise noted on the form, please return completed documents to TeamstersCare at Schrafft’s City Center, 529 Main Street, Suite 209, Charlestown MA 02129.
If you need assistance, or can’t find the form you’re looking for, please contact us.
TeamstersCare/Dental Blue Freedom
Member Forms
Request for a Certificate of Creditable Coverage
Request for Additional Information/Possible Third Party Claim Form
Blue Cross Blue Shield Fitness & Weight Loss Reimbursement Form
Pharmacy Forms
Express Scripts Mail-Order Form
Prescription Drug Direct Payment Claim Form for Retirees Age 65 and Over
Prescription Drug Reimbursement Form for Active and MSTS Members and Early Retirees
TeamstersCare General Medication Prior Authorization Request Form
Summaries of Benefits & Coverage
SBC – Active Out of Area Members
SBC – MSTS Out of Area Members
SBC – Early Retiree Members BCBS HMO
Summary Plan Descriptions
SPD – Active Dental/Vision Program
SPD – Early Retiree Medical Program
SPD – Over Age 65 Retiree Prescription Drug & Retiree Clinical Services and Vision Program
Notices
TeamstersCare Notice of Privacy Practices (HIPAA)
TeamstersCare a Grandfathered Plan Under the Affordable Care Act
Medicaid and the Children’s Health Insurance Program (CHIP) Notice
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