Forms and Resources

• 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

• Care Coordination
• MedImpact Choice 90 Program
• MedImpact Direct Mail Flyer 
• Preventative Care Services
• Proration Grid
• The ABC's of Explanation of Benefits (EOBs)
• ES Voucher 2024
• 2024 Abbott Freestyle & Precision Xtra free meter flyer

• 2024 LSU First Annual Notices
• HIPAA Privacy Practices 
• Medicare Part D Notice
• Your Rights and Protections against Surprise Medical Bills

• 2023 Summary Plan Document (SPD) 
• 2024 Plan Highlights Video
• 2023 Benefits Snapshot 
• 2024 Summary of Benefits and Coverage (SBC)*
• 2023 Premiums for Active Employees 
• 2023 Retiree Premiums 19%
• 2023 Retiree Premiums 38%
• 2023 Retiree Premiums 56%
• 2023 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 [email protected]. All official Minutes of the LSU Board of Supervisors from 1862 to the present are housed in the University Archives in Hill Memorial Library.