Group Administrator Links, Documents and Forms

Link to Online Administration Log-in Page Renewal Application Contact Customer Service
Carrier Forms:  Lifewise Assurance, Premera, VSP Medicare Secondary Payer / TEFRA Explanation
Other:  COBRA & CDHP, Enrollment Form, General Forms, Health Advocate,
Lifewise Assurance		Back to Top
Links	June 2012 - 2013 Plan Year	Prior Year Summaries
Lifewise Assurance Website Administrative Forms Beneficiary Change Form Group Life Claim Form	Base Life/AD&D: 10K Life/AD&D: 20K, 30K, 40K, 50K Short-term Disability: $300, $500 June 2012 - 2013 Plan Year (Booklets) Base Life/AD&D: 10K Life/AD&D Buy-Ups: 20K, 30K, 40K, 50K Short-term Disability: $300, $500	2011 Information 2010 Information
Premera		Back to Top
Links	June 2012 - 2013 Benefit Summaries  - GRANDFATHERED	June 2012 - 2013 Benefit Summaries  - NON-GRANDFATHERED
Premera Blue Cross Website Find a Provider (Directory) Preferred Drug List Administrative Guide Premera Claim Form Premera Deductible Credit Form HIPAA Release Form COBRA Application Enrollment Exception Request Form Alaska Conversion Plan Brochure Alaska Group Conversion Application Premera Brochure: How to Get the Most Out of Your Health Plan Walmart Pharmacy List	Classic 250 Classic 500 Frontier 750 Frontier 1000 Frontier 1500 Frontier 2000 Frontier 2500 Envoy 3000 Envoy 5000 Frontier HSA 2500 Frontier HSA 5000 Dental $1,000 Max Dental $1,500 Max Dental $2,000 Max Certificates (Booklets) 2012-13 Plan Year (Not Received as of 4-30-12) (Grandfathered and Non -Grandfathered) Classic 250 Classic 500 Frontier 750 Frontier 1000 Frontier 1500 Frontier 2000 Frontier 2500 Envoy 3000 Envoy 5000 Frontier HSA 2500 Frontier HSA 5000 Dental $1,000 Max Dental $1,500 Max Dental $2,000 Max	Classic 250 Classic 500 Frontier 750 Frontier 1000 Frontier 1500 Frontier 2000 Frontier 2500 Envoy 3000 Envoy 5000 Frontier HSA 2500 Frontier HSA 5000 Dental $1,000 Max Dental $1,500 Max Dental $2,000 Max
Vision Service Plan (VSP)		Back to Top
Links	Plan Summaries (2012-13 Plan Year)
VSP Website Provider Director Out of Network Provider Reimbursement Form	VSP $10/$25 VSP $0/$10
COBRA & CDHP (FSA, HRA, HSA, POP) - Benefit Solutions, Inc. - BSI		Back to Top
COBRA BSI COBRA Administrative Agreement Initial Notice Template FSA Flyer HRA Flyer HSA Flyer	CDHP Employer Forms BSI Cafeteria Plan Adoption Agreement CDHP Group Enrollment Form (FSA, HRA, HSA) CDHP Employee Forms Employee Enrollment Form HRA Employee Enrollment Form FSA
Health Advocate (Value-Added at no additional cost)		Back to Top
Health Advocate Core Features	Health Advocate Member Brochure
General Forms and Information		Back to Top
2012-13 Renewal Booklet 2012-13 Plan Comparison Renewal Application Medicare Secondary Payer / TEFRA Explanation 2012 Alaska Renewal Presentation (Adobe PDF)	Billing & Premium Process BSI Administrative Guide EFT Form Enrollment Form Individual Health Questionnaires