The Retirement Systems of Alabama

- ERS Members
- TRS Members
- RSA
- ERS
- TRS
- PEEHIP
- RSA-1
- JRF

Public Employees' Health Insurance Plan (PEEHIP)

PEEHIP Publications & Forms

Resources
PEEHIP Forms
PEEHIP Publications
Contact PEEHIP
PEEHIP Advisor
Online Tutorials
Actuarial Report
Financial Statements
Trust Fund Financials
HIPAA/PEEHIP Privacy Statement
Quick Links
RSA Home Page
Social Security
Blue Cross Blue Shield
MedImpact
Southland Benefit Solutions
VIVA HMO
Medicare
Alabama Vital Statistics
Medicare GenerationRx

All of the documents listed here require Adobe Reader version 8.0 or higher. To download the latest version, please scroll to the bottom of this page. If you experience trouble viewing any publications or forms, click here for information.

Publications
Open Enrollment Packet - effective October 1, 2012
Member Handbook- effective October 1, 2012
PEEHIP Advisor Newsletter

Retirees with Medicare- effective October 1, 2012
BCBS BeHealthy Newsletter
PEEHIP Hospital Medical Matrix of Benefits- Group #14000 - - effective May 5, 2012
PEEHIP Hospital Medical Matrix of Benefits- Group #14000 - - effective October 1, 2012
Supplemental Coverage Plan Matrix of Benefits- Group #61000 - effective October 1, 2011
BCBS Summary Plan Description - effective October 1, 2012 New!

FLEX Summary Plan Description - effective October 1, 2011
Health Care Flexible Spending Account Brochure - effective October 1, 2011
Health Care Flexible Spending Account Brochure - effective October 1, 2012
Flex Debit Card - effective October 1, 2012
Dependent Care Flexible Spending Account Brochure - effective October 1, 2011

Optional Plan Booklet- (cancer, dental, indemnity, vision) effective October 1, 2010
Optional Plan Brochure- (cancer, dental, indemnity, vision) effective October 1, 2010

GASB Statement 24 – On-Behalf Payments for K-14

GASB Statement 24 – On-Behalf Payments for Universities

Forms
Health Insurance Forms
Flexible Spending Accounts Forms
Other PEEHIP Forms

Fillable Form Instructions

We are in the process of replacing many of our forms with fillable forms. For more information about fillable forms, please click on the link above for instructions. As the fillable forms are added to the Publications & Forms pages of our Web site, they will be denoted by an asterisk (*) beside the form name.

Health Insurance Forms		back to top
	Health Insurance and Optional Enrollment Application
	Health Insurance and Optional Status Change
	Address Change Notification - Address changes can also be made using Member Online Services on the left of your screen
	Southland National Vision Claim Form
	Southland National Dental Claim Form
	Southland National Indemnity and Cancer Claim Form
	MedImpact Prescription Drug Claim Form
	MedImpact Prior Authorization Request Form
	Hospital Medical Claim Form - Group # 61000 and #14000


Flexible Spending Accounts Forms		back to top
	Flexible Spending Accounts Enrollment Application
	Flexible Spending Accounts Status Change
	Address Change Notification- Address changes can also be made using Member Online Services on the left of your screen
	Flexible Spending Accounts Direct Deposit Form
	Request for Reimbursement Form for Flexible Health Care Account
	Request for Reimbursement Form for Flexible Dependent Care Account
	Common OTC Meds Eligible for Your Health Care Spending Account - OTC medications will not be covered under your Flex Health Spending Account after January 1, 2011.


Other PEEHIP Forms		back to top
	Address Change Notification - Address changes can be made using Member Online Services on the left of your screen
	FPL Application
	Retiree Employment Verification
	Refund Request

Some information on this site requires Adobe Reader version 8.0 or higher. You can download the latest version for FREE! Just click the Get Adobe Reader button.

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