Insurance

Annual Tobacco User Premium Discount Application IB06

  INSTRUCTIONS: ALABAMA ANNUAL TOBACCO USER PREMIUM DISCOUNT APPLICATION (Form IB06)     Alabama state employees who are tobacco users apply for a premium on their insurance using a form
Read Full Article

Non-Tobacco User Discount Application IB05

  INSTRUCTIONS: ALABAMA NON-TOBACCO USER DISCOUNT APPLICATION (Form IB05)     Alabama state employees may apply for a discount on their state-administered health insurance if they are not tobacco users.
Read Full Article

Refund Request

  INSTRUCTIONS: REFUND REQUEST   Alabama public education employees who are enrolled in the Public Education Employees' Health Insurance Plan (PEEHIP) can request a refund from the program related to
Read Full Article

MedImpact Prior Authorization Request Form

  INSTRUCTIONS: MEDIMPACT MEDICATION REQUEST FORM    Alabama physicians and providers who need to treat a public employee enrolled in the state's PEEHIP program with a Prior Authorization drug must
Read Full Article

Hospital Medical Claim Form – Group 61000 and 14000

  INSTRUCTIONS: HOSPITAL MEDICAL CLAIM FORM - GROUP #61000 AND #14000   Alabama public employees enrolled in BlueCross/BlueShield groups 61000
Read Full Article

Flexible Spending Accounts Enrollment Application

  INSTRUCTIONS: FLEXIBLE SPENDING ACCOUNT ENROLLMENT APPLICATION    Alabama public employees who are active members of the state-administered PEEHIP health
Read Full Article

Flexible Spending Accounts Status Change

  INSTRUCTIONS: FLEXIBLE SPENDING ACCOUNT STATUS CHANGE   Alabama public employees who have enrolled in the flexible spending account program
Read Full Article

Flexible Spending Accounts Direct Deposit Form

  INSTRUCTIONS: FLEXIBLE SPENDING ACCOUNTS DIRECT DEPOSIT AUTHORIZATION FORM   Alabama public employees who are enrolled in the state PEEHIP
Read Full Article

Request for Reimbursement Form for Flexible Health Care Account

  INSTRUCTIONS: REQUEST FOR REIMBURSEMENT FORM FOR FLEXIBLE HEALTH CARE ACCOUNT   Alabama public employees who have a flexible health
Read Full Article

Request for Reimbursement Form for Flexible Dependent Care Account

  INSTRUCTIONS: REQUEST FOR REIMBURSEMENT PREFERRED DEPENDENT CARE ACCOUNT   Alabama public employees enrolled in the state PEEHIP program and who have a flexible account for dependent care can use
Read Full Article