Publications & Forms
Publications & Forms
Publications
- Member Handbook with Open Enrollment Information - effective October 1, 2014
- PEEHIP Advisor Newsletter
- BCBS BeHealthy Newsletter
- Retirees with Medicare - effective January 1, 2014
- PEEHIP Hospital Medical Matrix of Benefits - Group #14000 effective October 1, 2013
- Supplemental Coverage Plan Matrix of Benefits - Group #61000 effective October 1, 2013
- Flex Summary Plan Description - effective January 1, 2014
- Health Care Flexible Spending Account Brochure - effective October 1, 2013
- Flex Debit Card - effective October 1, 2013
- Dependent Care Flexible Spending Account Brochure - effective October 1, 2013
- Optional Plan Booklet - (cancer, dental, indemnity, vision) effective October 1, 2013
- Optional Plan Brochure - (cancer, dental, indemnity, vision) effective October 1, 2013
- VIVA Health Plan Certificate of Coverage
- VIVA Health Plan Summary of Benefits
- GASB Statement 24 - On-Behalf Payments for K-14
- GASB Statement 24 - On-Behalf Payments for Universities
Forms
Health Insurance Forms
- New Enrollment and Status Change
- 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
- Flexible Spending Accounts Enrollment Application
- Flexible Spending Accounts Status Change
- Flexible Spending Accounts Direct Deposit Form
- Request for Reimbursement Form for Flexible Health Care Account
- Request for Reimbursement Form for Flexible Dependent Care Account