Publications and Forms

Forms

• Claim Form
• GBP Supplemental Information (Primary Care Physician Selection) Forms
• HIPAA Authorization Form to Disclose Protected Health Information
• Transitional Benefits
• BlueCard Worldwide^® (For Out of Country Claims)
• Prescription Drug Claim Forms
• Medical Support Order Dependent Address Form

Publications

Plan Year 2012 Benefits Books

• For Active Employees (Regardless of Age) and Retirees Under Age 65  (1,431 KB)
• For Retirees Age 65 and Over  (1,001 KB)

Plan Year 2012 Benefit Highlights

• Plan Year 2012 Benefit Highlights for Employees (All Ages) and Retirees Under Age 65  (479 KB)
• Plan Year 2012 Benefit Highlights for Retirees Age 65 and Over * (604 KB)

* This information is about your benefits from September 1, 2011 under HealthSelect. These are your benefits as long as HealthSelect is your health plan. If you are eligible to receive benefits under the statewide Medicare Advantage PPO plan beginning January 1, 2012, please click here  to preview your upcoming benefits.

Health and Wellness

• Health and Wellness (for participants)
• Health and Wellness (for coordinators)

Archives

Plan Year 2011 Benefits Books

• For Active Employees (Regardless of Age) and Retirees Under Age 65  (1,214 KB)
• For Retirees Age 65 and Over  (1,509 KB)

• Benefits books from previous plan years
• Master Benefit Plan Documents from previous plan years

Plan Year 2011 Benefit Highlights

• For Active Employees (Regardless of Age) and Retirees Under Age 65  (478 KB)
• For Retirees Age 65 and Over  (631 KB)