Forms and Resources
Forms
- LSU First Enrollment Form: GB-01
- Medical Claim Form (WebTPA)
- Citizens Rx Prescription Drug Claim Form
- Citizens Rx Mail Order Prescription Delivery Registration Form
- First Choice Provider Nomination Form
- Aetna ASA Nomination Form
- Medical Necessity Form
- WebTPA HIPAA Form
- Citizens Rx HIPAA Form
- Certification of Adult Dependent Form
Resources
- 2019 LSU First Benefit Snapshot
- 2019 Summary of Benefits
- 2019 Premiums for Active Employees
- 2019 Premiums for Retirees
- 2019 LSU First Preferred Drug List
- 2019 LSU First Specialty Drug List
- 2019 LSU First Prior Authorization Drug List
- 2019 LSU First Drug Exclusion List
- Employee Assistance Program
- Citizens Rx Diabetic Meter
- Guide to WebTPA’s Explanation of Benefits
- Proration Guide
- EQ Health Care Coordination
- Diabetes Monitoring
- HIPAA Privacy Practice Effective 12/01/2020
- Marketplace Notice
- Medicare Part D Notice
- Preventative Care Guidelines