Brokers:
Individual Plans
INDIVIDUAL
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MEDICARE
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Complete an electronic application and upload the required documents
(For best results, please use Google Chrome as your browser.)
Forms
- Online search
- Active&Fit Fitness Benefit
- Member Guidebook
- Premium Payment Options
- Pediatric dental benefits
- Pediatric vision benefits
2021 plans:
- Comparison of Benefits
- 5 Tier Commercial Metal:
Annual Notice of Change
Online Search | PDF
Prior Authorization and Step Therapy Criteria - 5 Tier Commercial:
Annual Notice of Change
Online Search | PDF
Prior Authorization and Step Therapy Criteria - 3 Tier Commercial:
Annual Notice of Change
Online Search | PDF
Prior Authorization and Step Therapy Criteria - Application (PDF)
- Application (PDF) Spanish
- Change/termination form (PDF)
- Change/termination form (Spanish)
- Summaries of Benefits and Coverage (SBCs)
2022 plans:
- Comparison of Benefits
- 5 Tier Commercial Metal:
Online Search | PDF - Application (English)
- Application (Spanish)
- Change/termination form (PDF)
- Change/termination form (Spanish)
- Summaries of Benefits and Coverage (SBCs)
Last Updated: 1/10/2022