Forms and Resources
Forms
- LSU First Enrollment Form: GB-01
- Medical Claim Form (WebTPA)
- Prescription Drug Claim Form (MedImpact)
- First Choice Provider Nomination Form
- Aetna ASA Provider Nomination Form
- LSU First Prior Authorization Form
- WebTPA HIPAA Form
- MedImpact Rx HIPAA Form
- Certification of Adult Dependent Form
Resources
- 2023 Summary Plan Document (SPD)
- 2024 Plan Highlights Video
- 2024 Benefits Snapshot
- 2024 Summary of Benefits and Coverage (SBC)*
- 2024 Premiums for Active Employees
- 2024 Retiree Premums 19%
- 2024 Retiree Premums 38%
- 2024 Retiree Premiums 56%
- 2024 Retiree Premiums 75%
*A good faith effort is made to provide accessible documents. If you require assistance, please contact the LSU Board of Supervisors at lsuboard@lsu.edu. All official Minutes of the LSU Board of Supervisors from 1862 to the present are housed in the University Archives in Hill Memorial Library.