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Group Administrator Links

Documents and Forms

 

 

 

Health Plan Forms

 

Administrative Forms

HIPAA Authorization Forms

RX Reimbursement Form

CVS Caremark Rx Mail Order Form

CVS Caremark Rx Mail Order Instructions

 

Aug10-Jul11 Plan Summaries

(Posted 8-24-10; Revised 11-16-10)

 Health Net

PPO $250

PPO $500

PPO $750

PPO $1000

PPO $1500

PPO $2500

PPO $3000

50/50 $2500 Ded.

50/50 $5000 Ded.

RX $10/$20/$40

RX $10/$50/$75

RX $15/$30/$50

RX $15/30%/50%

PPO Contract

PPO Contract Changes


HSA Qualified Plan Summaries

HSA $1500 Single

$3000 Family

HSA RX 20% (included with all HSA Plans)

 

Health Net Links

Health Net Website

Provider Search


Complimentary Care Network

Effective 1/1/2011

Optum Health 877-369-2195

Optum Health - Complimentary Care 1/1/11

Optum Health Provider Directory


 

VSP Vision Plans

VSP $10/25

VSP $0/10

VSP Website

Provider Directory

 

Guardian Dental Plans

Plan 1000

Plan 1000 With Ortho

Plan 1500

Plan 1500 With Ortho

Plan 2000

Plan 2000 With Ortho

Guardian Maximum Rollover Handout

 

Other Products

Resources for Living EAP Flyer

LifeBalance Program Flyer

 
 

Life Insurance Plans

$10,000 Life / AD&D

$20,000 Life / AD&D

$30,000 Life / AD&D

$40,000 Life / AD&D

$50,000 Life / AD&D

 

 

Miscellaneous Summaries

Pharmacy Disclosure

Pharmacy Benefit Guide

Domestic Partner Rider

24 Hour Coverage

Flu Shot Policy

 

General Forms

 

Enrollment

Employee Enrollment Form

Domestic Partner Affidavit

 

Billing & Premium Process

BSI Admin/Reference Guide

EFT Form, Terms & Conditions

 

COBRA Administration

BSI Administrative Agreement

 

 

 

 

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