Publications and Forms

Forms

• Benefit/Wellness Fair Presentation Request Form
• Domestic Claim Form 
• International Claim Form 
• Nominate a provider
• Transition of care 

Plan Year 2018 Summary of Benefits and Coverage (SBC)

• PY 2018 HealthSelect (In-Area) SBC 
• PY 2018 HealthSelect (In-Area) SBC Spanish 

• PY 2018 HealthSelect Out-of-State SBC 
• PY 2018 HealthSelect Out-of-State SBC Spanish 

• PY 2018 HealthSelect Secondary SBC 
• PY 2018 HealthSelect Secondary SBC Spanish 

• PY 2018 Consumer Directed HealthSelect SBC 
• PY 2018 Consumer Directed HealthSelect SBC Spanish 

• SBC Glossary of Health Coverage and Medical Terms