Group Application / Enrollment Forms

• Small Group HMO/POS application (Groups of 2-50)
• Small Group HMO/POS Enrollment/Change Form (Groups 2-50)
• Small Group PPO Enrollment/Change Form (Groups 2-50)
• Small Group new enrollment checklist
• Large Group HMO/POS application (Groups of 51+)
• Large Group HMO/POS Enrollment Change Form (Groups of 51+)
• Large Group PPO Enrollment Change Form (Groups of 51+)
• Continuation of coverage form
• Large Group new enrollment checklist

Other Forms

• Common ownership verification
• Continuation of coverage form
• Small Group Employer eligibility agent worksheet
• Healthy lifestyle rebate form
• Participation validation
• Appoint a representative - authorize someone to act on your behalf
• Tobacco Attestation
• Coordination of Benefits Questionnaire
• Other Coverage Form

Pharmacy / Medical Orders & Authorizations

• Order mail order prescriptions online
• Pharmacy authorization/exception request form - must be completed and submitted by your physician
• Prescription mail order form
• Prescription drug reimbursement form
• Medical reimbursement form

General Information

• Member Guidebook - Except TPA plans
• Fitness Membership (Active&Fit)
• Healthy Living Program
• Covered Preventive Services
• Provider Directory
• Urgent Care
• More About our Secure Web Site
• Member rights and responsibilities
• Notice of privacy practices
• Health education programs
• Transparency in Coverage