Publications & Forms
Publications & Forms
Publications
- Member Handbook with Open Enrollment Information - effective October 1, 2017
- PEEHIP Advisor Newsletter
- PEEHIP info
- PEEHIP Summary Plan Description
- BCBS BeHealthy Newsletter
- 2016 PEEHIP Funding Sources
- 2016 PEEHIP Funding Usage
- PEEHIP Hospital Medical Matrix of Benefits - Group #14000 effective January 1, 2018
- Supplemental Medical Plan Matrix - Group #61000 effective January 1, 2017
- Supplemental Medical Plan Matrix - Group #61000 effective January 1, 2018
- Flex Summary Plan Description - effective October 1, 2017
- Flexible Spending Accounts (FSA) Brochure - effective October 1, 2017
- Optional Plan Booklet - (cancer, dental, indemnity, vision) effective October 1, 2017
- Optional Plan Brochure - (cancer, dental, indemnity, vision) effective October 1, 2017
- VIVA Health Plan Certificate of Coverage - effective October 1, 2017
- VIVA Health Plan Matrix of Benefits - effective October 1, 2017
- UnitedHealthcare Plan Guide (MAPD) - effective January 1, 2018
- UnitedHealthcare Plan Guide (MA Only) - effective January 1, 2018
Forms
Health Insurance Forms
- New Enrollment and Status Change
- Southland Benefit Solutions Vision Claim Form
- Southland Benefit Solutions Dental Claim Form
- Southland Benefit Solutions Indemnity and Cancer Claim Form
- MedImpact Prescription Drug Claim Form
- MedImpact Prior Authorization Request Form
- Hospital Medical Claim Form - Group #14000 and #61000
Flexible Spending Accounts Forms
- Flexible Spending Accounts Enrollment Application
- Flexible Spending Accounts Status Change
- Flexible Spending Accounts Direct Deposit Form
- Healthcare Flexible Spending Account Reimbursement Form HealthEquity
- Dependent Care Reimbursement Account Reimbursement Form HealthEquity
- Orthodontia Reimbursement Form