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Account Log-in (BSI site for Billing and Eligibility Changes)
Contact
Customer Service
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Carrier Forms Quick Links: Health Net, Lifewise Assurance, Guardian Dental, Superior Vision, LifeBalance,
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Other Quick Links: COBRA & CDHP, Enrollment/Change/Waiver Forms, General Forms
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Lifewise
Assurance - Life and STD
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Back to Top
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Links
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Benefit Summaries
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Certificates/Booklets
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Lifewise Assurance Website
Administrative Forms
Beneficiary
Change Form
AGC
Group Life Claim Form
STD Claim Form
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$10,000 Life/AD&D
Certificate (2-9 Employees)
$20,000 Life/AD&D
Certificate (2-9 Employees)
$10,000 Life/AD&D
Certificate (10+ Employees)
$20,000 Life/AD&D
Certificate (10+ Employees)
$30,000 Life/AD&D
Certificate (10+ Employees)
$40,000 Life/AD&D
Certificate (10+ Employees)
$50,000 Life/AD&D
Certificate (10+ Employees)
STD $300 13 Weeks
STD $500 13 Weeks
STD $300 26 Weeks
STD $500 26 Weeks
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$10,000 Life/AD&D Plan Summary
$20,000 Life/AD&D Plan Summary
$30,000 Life/AD&D Plan Summary
$40,000 Life/AD&D Plan Summary
$50,000 Life/AD&D Plan Summary
STD $300 13 Weeks
STD $500 13 Weeks
STD $300 26 Weeks
STD $500 26 Week
LifeWise Policy
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Health Net - Medical, RX
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Back to To
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Links
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Benefit Summaries PPO
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Benefit Summaries - Essentials
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HealthNet
Website
Provider
Search
Pharmacy
Search
Administrative Forms
HIPAA
Authorization Forms
State Continuation Election Form
CVS
Caremark Rx Mail Order Form
CVS
Caremark Rx Mail Order Instructions
RX Reimbursement
Form
Miscellaneous Documents
Member Handbook
Decision Power
Pharmacy Benefit Guide
Healthy Discounts
Prior Authorization Requirements
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PPO $250 (A15-250-2-2500)
PPO $500 (Only Available to those currently enrolled)
PPO $750 (GSA-20-750-2-2500)
PPO $1000 (A25-1000-2-3000)
PPO $1500 (A30-1500-2-3000)
PPO $2000 (GSA30-2000-2-4000)
PPO $3000 (A30-3000-2-3000)
PPO $5000 (A35-5000-2-3000)
PPO $7500 (GSA35-7500-2-5000)
Value $1000 (Only available to those currently enrolled)
50-50-2500 (Only available to those currently enrolled)
50-50-5000 (Only available to those currently enrolled)
Benefit Summaries RX
RX $10/$25/$50
RX $15/$30/$50
RX $10/$50/$75
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Essential $1000 (GSE25-1000-3-5000)
Essential $2000 (GSE30-2000-3-5000)
Essential $3000 (GSE35-3000-3-5000)
Essential $5000 (GSE35-5000-3-5000)
Essential $7500 (GSE35-7500-3-5000)
Other Riders
HN Well Net Benefit
Buy-Up Options
HN Well Net Buy-Up
Plan Contract
PPO Plan Contract - 2012
PPO 2012 Summary of Contract Changes
Prior Year Benefit Summaries
2011 Benefit Summaries
2010 Benefit Summaries
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Superior Vision
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LifeBalance
Back to Top
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Links
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Benefit Summaries
Group Plans (enrollment must follow medical enrollment)
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Links
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Superior Vision Website
Getting Started with Superior
Member Guide
Provider Nomination Form
Overview - Finding a Provider
Provider
Directory - web search
S.V. HIPAA Notice (PDF)
S.V. Privacy Notice (PDF)
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Plan 100
Plan 150
Plan 100/150 Comparison
Plan 100 Certificate
Plan 150 Certificate
Amendment to Age 26
Voluntary Plans (employee paid; no minimum enrollment required)
Plan 100V
Plan 150V
Plan 100V/150V Comparison
Plan 100V Certificate
Plan 150V Certificate
Amendment to Age 26
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LifeBalance
Website
Provider
Network
LifeBalance
Benefits
LifeBalance
Program Flyer
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Guardian Dental
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Links
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Benefit Summaries
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Certificate Booklets
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Guardian Provider Search
Guardian Dental Maximum Rollover
Handout
Maximum
Rollover for Guardian Plan 1000
Maximum
Rollover for Guardian Plan 1500
Maximum
Rollover for Guardian Plan 2000
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Guardian Plan
1000
Guardian Plan 1000 w/
Ortho
Guardian Plan
1500
Guardian Plan 1500 w/
Ortho
Guardian Plan
2000
Guardian Plan 2000 w/
Ortho
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COBRA & CDHP –
Benefit Solutions, Inc. (BSI)
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Back to Top
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COBRA
BSI COBRA Administration Information
BSI COBRA Administrative Agreement
Initial
Notice Template (Employer must distribute)
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CDHP
BSI Cafeteria Plan Adoption Agreement
CDHP Group Enrollment Form
CDHP Group Enrollment Form
BSI
CDHP Employee Enrollment Form - FSA
BSI CDHP Employee Enrollment Form
- HRA
BSI
CDHP Employee Enrollment Form - HSA
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BSI FSA/HSA/HRA Administration
Information
BSI
Reference Guide
BSI CDHP
Information
CDHP Informational Flyers
FSA/HSA/HRA Flyer with Pricing
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General Forms
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Back to Top
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Enrollment/Change/Waiver
Form
Domestic Partner Affidavit
Program Highlights
State Continuation
Election Form
Medicare Secondary Payer / TEFRA
Explanation
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Billing & Premium
Process
BSI
Reference Guide
EFT Form, Terms &
Conditions
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SPD Documents
2012 Summary Plan Description (SPD)
2012 SPD Letter to Employers
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