Member Enrollment
- 2025 LGHIP Health Enrollment Form (LG01)
- 2025 LGHIP Member Information Changes Form (LG02)
- 2025 LGHIP Retiree Coverage Enrollment Form (LG22)
- 2025 LGHIP New Dependent Form (LG02-B)
- 2025 LGHIP Dependent Cancellation Form (LG02-C)
- 2025 LGHIP Cancellation Form (LG03)
- 2025 LGHIP Declination of Coverage Form (LG04)
- 2025 LGHIP ACA Verification Form (LG23)
- 2025 Automatic Payments (COBRA) (LG14)
Claims
- OptumRx Prescription Reimbursement Request Form
The deadline to submit the Direct Member Reimbursement (DMR) by mail to OptumRX for eligible 2024 tier 2 and 3 prescription drugs is February 28, 2025.
- BC/BS Medical Expense Claim Form
