Forms & benefit information

2026 Benefit Summaries

• SAIF Active Plan (PDF)
• SAIF Prescription Drug Plan (PDF)
• SAIF Early Retiree Plan (PDF)
• SAIF Early Retiree Prescription Drug Plan (PDF)

2025 Benefit Summaries

• SAIF Active Plan (PDF)
• SAIF Prescription Drug Plan (PDF)
• SAIF Early Retiree Plan (PDF)
• SAIF Early Retiree Prescription Drug Plan (PDF)

• 2026 Summary Plan Description (SPD) (PDF coming soon)
• 2025 Summary Plan Description (SPD) (PDF)

As part of the Patient Protection and Affordable Care Act, we are required to provide you with a document called a Summary of Benefits and Coverage (SBC). This document outlines and explains your plan's health benefits and coverage. The SBC is designed to help you easily understand the basic details of your plan, although it does not replace the detailed benefit summary. Since all insurance companies use the same format for the SBC, you can easily compare different health plans and their offerings. This helps you choose the best option for your healthcare needs.

Learn more

2026 SBCs

• SAIF Active Plan (PDF)
• SAIF Early Retiree Plan (PDF)

2025 SBCs

• SAIF Active Plan (PDF)
• SAIF Early Retiree Plan (PDF)

Members enrolled in the Providence Signature network plan are required to select a primary care provider. To make your selection:

• Log in to your My Collective® account.
• Navigate to the Get Care provider search and choose a provider.
• Click ‘Set as my primary care provider.’

Need help? Member Advocates are available to assist you. Call your dedicated line at 844-945-4148, Monday - Friday, 4 a.m. to 6 p.m., and Saturday, from 7 a.m. to 11 a.m. (Pacific Time).

For health care services on or after January 1, 2026:

Most providers bill to Providence Health Plan Powered by Collective Health directly, however there may be times when you need to submit a medical claim.

To be reimbursed for health care services, you will need to submit a claim through your My Collective® online portal or mobile app using the following steps:

 

• Log in to your My Collective account.
• At the top of the page, go to "Activity"
• Click "Submit a claim."

Need help? Call a Member Advocate at 844-945-4148, Monday - Friday, 4 a.m. to 6 p.m., and Saturday, from 7 a.m. to 11 a.m. (Pacific Time).

Please use the following forms for services received prior to January 1, 2026 and submit your completed form to Providence Health Plan:

• Medical claim form (PDF)
• Alternative care claim form for providers (PDF)
• Medical travel reimbursement form (PDF)
• Transplant travel reimbursement form (PDF)

• Prescription drug reimbursement request form (PDF)
• Prescription drug prior authorization form (PDF)
• Uniform prior authorization prescription request form (PDF)

• PHI Authorization Form (PDF)
• PHI Authorization Form (Spanish) (PDF)
• Appointment of Authorized Representative (PDF)
• Appointment of Authorized Representative (Spanish) (PDF)
• Confidential Communication Request Form (PDF)
• Restriction Request Form (PDF)

• Continuity of Care and Transition of Care request (PDF)

You have the right to review an internal appeal. This allows you to ask Providence Health Plan Powered by Collective Health to reconsider a decision about coverage or payment for medical services. They'll review and may reverse their initial decision.

• Request for internal appeal form (PDF)

If Providence Health Plan Powered by Collective Health denies coverage or payment for medical services and you disagree with their decision, you can request an external review. This is done by an independent third party. They’ll review the situation and make a final decision.

• External review request form (PDF)