Plan Documents
Below are some useful resources and forms for each of the plan options.
2027 Plan Documents
- Benefits Comparison Chart (PDF)
- 2027 Plan Information Booklet (PDF)
English | Spanish - 2027 BlueChoice Brochure (PDF)
- Proof of Coverage and Tax Identification Number (TIN) Collection FAQs (PDF)
- Medical Policy
- Contraception Coverage (PDF)
- Disputed Claims Process (PDF)
- PSHB and Medicare At A Glance (PDF)
2026 Plan Documents
- Benefits Comparison Chart (PDF)
- 2026 Plan Information Booklet (PDF)
English | Spanish - 2026 BlueChoice Brochure (PDF)
- Proof of Coverage and Tax Identification Number (TIN) Collection FAQs (PDF)
- Medical Policy
- Contraception Coverage (PDF)
- Disputed Claims Process (PDF)
- 2026 Postal Service Health Benefits Program and Medicare Prescription Drug Plan (PDF)
- PSHB and Medicare At A Glance (PDF)
Plan Forms
- Coordination of Benefits (PDF)
- HSA/HRA Selection Form (PDF)
- Medical Claim Form (PDF)
- Prescription Mail Order Form (PDF)
- Prescription Reimbursement Claim Form (PDF)
- Social Security Number Submission Form (PDF)
- Vision Claim Form - Davis (PDF)
- International Claim Form (PDF)
(for members receiving care outside of the U.S.)
2026 Medicare Rx (PDP) Documents
- PSHBP Medicare Rx 2 Summary of Benefits (BlueChoice Advantage HDHP) (PDF)
- PSHBP Medicare Rx 4 Summary of Benefits (Blue Value Plus) (PDF)
- 2026 Medicare Rx Evidence of Coverage (PDF)
- 2026 Annual Notice of Change (PDF)
English | Spanish - Designation of Personal Representative Form (PDF)
(Use this form to designate someone who will be authorized to make health care coverage decisions on your behalf.)