SSM Health employee out-of-area employee/family form

If you or a covered family member reside outside of the SSM Employee Health Plan network service area, you may be eligible to have your medical claims covered as out of area.

Any eligible out-of-area member regardless of region will have access to both Multiplan and PHCS networks. To find out more or search for providers, visit

Notify us

To determine if you are eligible, review the list of SSM Employee Health Plan network zip codes. If your home zip code isn't listed, complete and submit this form. 

This benefit is for SSM Health employees on the WellFirst Health plan. If you have questions about your health plan and covered benefits, contact our Customer Care Center at 877-274-4693 (TTY:711).

Eligibility information is subject to auditing. I certify that all information on this affidavit is true, correct and current as of the date submitted