Health Plan Forms
At some point, you may need to access these forms to make changes, appeal a claim decision or submit a claim. Below are direct links to the forms needed for your particular circumstance. If you are unsure of which form you need, you may contact the Office of Human Resources or contact the State of Louisiana, Office of Group Benefits directly at (800) 272-8451.
New employees complete this form and return to HR within 30 days of their hire date. This form can also be used for an enrollee experiencing a qualifying event and needs to make a change to his/her coverage.
New employees wishing to enroll in a Flexible Spending Arrangement complete this form and return to HR within 30 days of their hire date. This form can also be used for an enrollee experiencing a qualifying event and needs to make a change to his/her coverage or enrolling in an FSA during the annual enrollment period.
Members must use this form for name changes or address changes and send it to the Office of Group Benefits – Eligibility section. Members can also make changes to their name or address on LEO (LaGov paid employees only).
This form is completed by the member to automatically debit their checking account to pay premiums along with required attached documents
This form is required when a member is submitting information for continued coverage on an incapacitated dependent child.
If a member disagrees with the participation statement the Office of Group Benefits (OGB) provided to them and their human resources department, the member is allowed to provide evidence of the number of years they participated in an OGB-offered health plan. If that information is not available them, the member may request that OGB research their participation further by completing this form and returning it to OGB.
The member completes this form to receive reimbursements quarterly when CMS advises. The member is responsible for monthly surcharges on Part D drugs due to high income.
• This program serves as additional coverage for retired members who have extensive hospital bills and/or large amounts of physician charges. Retiree 100 is available to members that are enrolled in a Magnolia Open Access Plan/ and Medicare is the primary insurer. The member completes this form for enrollment. You can enroll within 30 days before or after the date you become eligible for Medicare (Part A and B) during annual enrollment or 30 days before or after retirement.
• This form is sent to members 30/90 days prior to the plan member/spouse reaching the age of 65 giving important information about changes that may affect their OGB Health coverage.
Health Savings Account Enrollment & Payroll Deduction Election/Change Form.
Plan member/spouse/parent/guardian/provider or authorized delegate. This form must be completed within 180 days of the denial and submitted to Blue Cross Blue Shield Appeals and Grievance Coordinator.
Plan member completes this form for flu vaccination claims that are not filed by a network provider.
Member completes this form to request an HSA transfer or rollover. A rollover is a way to move money or property from a Medical Savings Account (MSA) or existing Health Savings Account (HSA) to a new HSA.
Use this form when you have paid full price for a prescription drug at a retail pharmacy or need to submit claims under Coordination of Benefits rules.
These and other forms can also be found at the State of Louisiana, Office of Group Benefit’s website at: OGB.