Group Application / Enrollment Forms

• Small Group Application (Groups of 2-50)
• Small Group Enrollment/Change Form (Groups 2-50)
• Small Group Renewal Form (Groups 2-50)
• Small Group new enrollment checklist
• Large Group Application (Groups of 51+)
• Large Group Enrollment Change Form (Groups of 51+)
• Large Group new enrollment checklist

Other Forms

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

Pharmacy / Medical Orders & Authorizations

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

General Information

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

Last updated: 10/26/2018