Preferred Provider (PPB) Plans

If a form has (Complete Form Online) next to it, you can complete it online by going to Manage My Benefits. It's easier, faster and leads to fewer mistakes than printing a form and sending it to PEIA.

Forms
Change-in-Address Form (Complete Form Online)
Coordination of Benefits Form
Comprehensive Care Program Enrollment Form
Court-Ordered Dependent Claim Packet
Dependent Out-of-Area Benefit Form
Dependent Qualification Affidavit
Discount Waiver Request Form
HIPAA Authorization Form
Improve Your Score Premium Discount Form
Medical Claim Form
Medical Home ID Card Request Form
Medical Home Member Application and Physician Selection Form
Patient Audit Form
Prescription Drug Claim Form
Request for Prior Approval of Services Form
Transition of Care Form

Documents
Comprehensive Care Program Provider Directory
Eligibility Documentation Memo
Medical Home Physician Directory
Premium Conversion Plan Information