Find a Form or Document


The following is an alphabetical list of forms and documents on the Web site.

If you see (Complete Online) next to a form, you can do this 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.

 ***If you have previouly had PEIA as your insurance carrier, you are unable to use Manage My Benefits to log in and enroll. 
Please see your HR department to fill out paper enrollment forms.

Forms

ABA Services Preauthorization Form
Annual Routine Physical and Screening Examination Form
Authorization to Release/Disclose Form
Authorization to Remove Coordinator Form
Basic and/or Optional Life Insurance Change of Beneficiary Form (Complete Online)
Basic Life Insurance Enrollment Form (Complete Online)
Change-in-Address Form (Complete Online)
Change-in-Status Form (Complete Online)
Combined Leave Form
Comprehensive Care Program Enrollment Form

Coordination of Benefits Form
Court-Ordered Dependent Claim Packet
Direct Draft Form
Disabled Dependent Eligibility Application
Electronic Funds Transfer Form
Health Benefits Enrollment Form (Complete Online)
HealthCheck Forms
Healthy Tomorrows Reporting Form (Plan Year 2019)
Medical Claim Form
Medical Travel Expense Reimbursement Request Form
Mountaineer Flexible Benefits Enrollment Form (Active Employees)

Mountaineer Flexible Benefits Enrollment Form (Retirees)
Notice of Death Form
Optional Life Insurance and Dependent Life Insurance Enrollment Form (Complete Online)
Out-of-Area Dependent Benefit Form
Out-of-state Waiver Form
Patient Audit Form
Pick a PCP Form
Premium and Benefit Assistance Form (Medicare)
Premium Assistance Form (non-Medicare)
Prescription Drug Claim Form
Provider Demographic Worksheet
Provider Request for More Information Form
Request for Prior Approval of Services Form
Retired Employee's Optional and Dependent Life Insurance Enrollment Form
Retirement Health Benefits and Basic Life Insurance Enrollment Form
Sample CCP Provider Contract
Surviving Dependents Health Benefits Enrollment Form
Suspected Insurance Fraud Citizen Reporting Form
Transition of Care Form
Termination Form (Complete Online)
Waiver of Premium Forms


Documents
ACA Reporting
Beneficiary Financial Counseling Brochure

Benefit Coordinators Reference Manual
Common Specialty Medications
Comprehensive Care Program Provider Manual
Dependent Documentation Memo
Directions to PEIA
Explanation of Benefits (sample)
Facility Fee Limits 
FAQs about Medicare Retiree Changes
FAQs Small Business Health Insurance Plan
Face to Face Diabetes Management Brochure
Full Formulary Listing
Healthy Tomorrows Pick a PCP
H1N1 (Swine Flu) Virus Fact Sheet
Legal, Financial Girief and Legacy Planning Services 
Life Insurance Benefits Booklet
Maintenance Medications List
Medicare Advantage Plan Booklets
Medicare Advantage Drug Formulary
Medicare Shopper's Guides
Mountaineer Flexible Benefits Plan (Active Employees)
Mountaineer Flexible Benefits Plan (Retirees) 
Nicotine Replacement Therapies
Notice of Privacy Practices
OPEB Plan Participation Standards
Preferred Drug List
Premium Conversion Plan Information
Preventative Drug List
Prior Authorization/Drugs with Special Limitations
Provider Directory
Retail Maintenance Network (RMN) of Pharmacies in West Virginia
Retail Maintenance Network (RMN) of Pharmacies Outside of West Virginia

River Valley Health Alliance Termination Letter
Shopper’s Guides
Special Medicare Plan Booklets
Summary Plan Descriptions
Travel  Assistance Brochure
Washington County Provider Network
Weight Management Brochure



Other Information
Fee Schedules & Manuals
Financial Reports
Wellness Tools
Health Tips
Historic Fee Schedules
Policies
Premium Rates
Requests for Proposals / Requests for Quotations