Out-of-Area Dependent Form

Prevea360 Health Plan is committed to helping your out-of-area dependents (up to age 26) get the coverage they need when they need it. Students who attend college out-of-town or children who live in another community are common examples of out-of-area dependents.

This benefit only applies to those with employer-sponsored large group plans. If you have questions about your health plan and covered benefits, please contact Prevea360 Health Plan's Customer Care Center.
Where dependent will be living.