SSM Health employee out-of-area dependent 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.

To find out more or search for providers, visit

Before seeking medical care with First Health providers, we suggest confirming your provider's First Health network participation status at Find out how to search for a First Health provider.

If you have questions, contact the member services at 877-274-4693.

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 enrolled in the health plan. If you have questions about your health plan and covered benefits, contact member services at 877-274-4693 (TTY:711).

* Required field

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