Forms & Documents
Information and Guidelines
GENERAL INFORMATION
ENROLLMENT AND NETWORK INFORMATION
REIMBURSEMENT FORMS
CARRIER PRESCRIPTION LISTS
Webinars
- HealthPass - The Solution For Your Small Business Clients Slide Deck 4/20/2023
- HealthPass - The Solution For Your Small Business Clients Video 4/20/2023
- HealthPass - What's in store for 2024 Slide Deck 10/5/2023
- HealthPass - What's in store for 2024 Video 10/5/2023
- Healthfirst Strategy Deck 2/9/2023
- Healthfirst Strategy Video 2/9/2023
- Introducing Anthem Deck 1/27/2023
- Introducing Anthem Video 1/27/2023
AGENT/BROKER CREDENTIALING
Ancillary & Additional Products
Dental Products For Effective Dates 10/1/2023 and After
- Guardian Byte
- Guardian DentalGuard Preferred For Effective Dates 10/1/2023 - 12/1/2023
- Guardian DentalGuard Preferred MAC 1/1/2024 and After
- Guardian DentalGuard Preferred Plus MAC For Effective Dates 10/1/2023 - 12/1/2023
- Guardian DentalGuard Preferred PPO 70 UCR 1/1/2024 and After
- Guardian DentalGuard Preferred PPO 90 UCR 1/1/2024 and After
- Guardian Managed DentalGuard For Effective Dates 10/1/2023 and After
- Guardian Managed DentalGuard Plus Effective Dates 10/1/2023 and After
- Solstice Dental EPO S700B For Effective Dates 10/1/2023 and After
- Solstice Dental EPO S800B For Effective Dates 10/1/2023 and After
- Solstice Dental PPO For Effective Dates 10/1/2023 and After
- Solstice Dental Value PPO MAC For Effective Dates 10/1/2023 and After
- UHC INO 100.50.50 For Effective Dates 10/1/2023 and After
- UnitedHealthcare High PPO MAC For Effective Dates 10/1/2023 and After
- UnitedHealthcare Low PPO MAC For Effective Dates 10/1/2023 and After
- UnitedHealthcare Select Care DMO For Effective Dates 10/1/2023 and After
- UnitedHealthcare SmileDirectClub
Dental Products For Effective Dates 9/1/2023 and Prior
- Guardian DentalGuard Preferred For Effective Dates 9/1/2023 and Prior
- Guardian DentalGuard Preferred Plus For Effective Dates 9/1/2023 and Prior
- Guardian Managed DentalGuard For Effective Dates 9/1/2023 and Prior
- Guardian Managed DentalGuard Plus For Effective Dates 9/1/2023 and Prior
- Solstice Dental EPO S700B For Effective Dates 9/1/2023 and Prior
- Solstice Dental EPO S800B For Effective Dates 9/1/2023 and Prior
- Solstice Dental PPO For Effective Dates 9/1/2023 and Prior
- Solstice Dental Value PPO MAC For Effective Dates 9/1/2023 and Prior
- UnitedHealthcare High PPO MAC For Effective Dates 9/1/2023 and Prior
- UnitedHealthcare INO 100.50.50 For Effective Dates 9/1/2023 and Prior
- UnitedHealthcare Low PPO MAC For Effective Dates 9/1/2023 and Prior
- UnitedHealthcare Select Care DMO For Effective Dates 9/1/2023 and Prior
Vision
FSA & Commuter Benefits
Disability/Life/AD&D
Accident
Health, Wellness & Cosmetic
ID Theft
Pet
Extra Products & Services
Enrollment Forms
Enrollment Change Forms 2022
ENROLLMENT CHANGE FORMS 2023
Enrollment Change Forms 2024
ENROLLMENT MATERIALS
- Common Law Employee Attestation Form
- Domestic Partner Affidavit
- EE Census Information Template
- Employer EFT/ACH Form
- EverGuard Conversion Form
- Group Attestation Form
- HealthPass Small Employer Exception Form
- Member Authorization Form
- New Group COBRA Member/Takeover Form
- Notice of Election Group Application 10/1/2023 - 12/1/2023
- Notice of Election Group Application 2024
- Open Enrollment Email Template
Renewal Forms
HealthPass Online Portal (HOP) Renewal Guides
Renewal Forms & Documents 2023
Renewal Forms & Documents 2024
Renewal Plan Mapping 2023
Renewal Plan Mapping 2024
Summary of Benefits
2024 Summary of Benefits and Coverage (SBC)
- Anthem Blue Access Gold EPO 50/55
- Anthem Blue Access Silver EPO 30/75
- Anthem Blue Access Silver EPO HSA 3250
- Anthem Connection Gold EPO 25/55
- Anthem Connection Gold EPO 50/55
- Anthem Connection Platinum EPO 20/40
- Anthem Connection Silver EPO 40/80
- Anthem Platinum EPO 5/25
- Anthem Silver EPO 40/80
- Anthem Silver EPO HSA 4000
- EmblemHealth Select Care Bronze HSA
- EmblemHealth Select Care Bronze Premier
- EmblemHealth Select Care Gold Premier
- EmblemHealth Select Care Platinum Premier
- EmblemHealth Select Care Silver HSA
- EmblemHealth Select Care Silver Premier
- Oxford Liberty Bronze HSA 5750
- Oxford Liberty Gold 30/60 G
- Oxford Liberty Gold EPO 25/50 ZD
- Oxford Liberty Gold EPO 30/60
- Oxford Liberty Gold HSA 1600 M
- Oxford Liberty Platinum EPO
- Oxford Liberty Silver 40/80
- Oxford Liberty Silver EPO 30/60 G
- Oxford Liberty Silver EPO 50/100 ZD
- Oxford Liberty Silver HSA 4000 M
- Oxford Metro Bronze HSA 7250 G
- Oxford Metro Gold 25/40
- Oxford Metro Gold 25/40 G
- Oxford Metro Silver EPO 30/80 G
- Oxford Metro Silver EPO 50/100 ZD
2023 SUMMARY OF BENEFITS AND COVERAGE (SBC)
- Anthem Blue Access Gold EPO 30/55
- Anthem Blue Access Silver EPO 25/50
- Anthem Blue Access Silver EPO HSA 3000
- Anthem Connection Gold EPO 25/50
- Anthem Connection Gold EPO 30/55
- Anthem Connection Platinum EPO 20/40
- Anthem Connection Silver EPO 40/70
- Anthem Platinum EPO 5/25
- Anthem Silver EPO 40/70
- Anthem Silver EPO HSA 3500
- EmblemHealth Prime Bronze HSA
- EmblemHealth Prime Bronze Premier
- EmblemHealth Prime Gold Premier
- EmblemHealth Prime Platinum Premier
- EmblemHealth Prime Silver HSA
- EmblemHealth Prime Silver Premier
- Healthfirst Gold 1350 Pro Plus EPO
- Oxford Liberty Bronze HSA 5750
- Oxford Liberty Gold 30/60 G
- Oxford Liberty Gold EPO 25/50 ZD
- Oxford Liberty Gold EPO 30/60
- Oxford Liberty Gold HSA 1500 M
- Oxford Liberty Platinum EPO
- Oxford Liberty Silver 30/60 G
- Oxford Liberty Silver EPO 40/80
- Oxford Liberty Silver EPO 50/100 ZD
- Oxford Liberty Silver HSA 4000 M
- Oxford Metro Bronze HSA 7000 G
- Oxford Metro Gold 25/40
- Oxford Metro Gold EPO 25/40 G
- Oxford Metro Silver 50/100 ZD
- Oxford Metro Silver EPO 30/80 G
2023 RESUMEN DE LA COBERTURA DE BENEFICIO (SBC)
- 2023-0297_Sp_2023_EmblemHealth_Bronze HSA
- 2023-0297_Sp_2023_EmblemHealth_Bronze Premier
- 2023-0297_Sp_2023_EmblemHealth_Gold Premier
- 2023-0297_Sp_2023_EmblemHealth_Platinum Premier
- 2023-0297_Sp_2023_EmblemHealth_Silver HSA
- 2023-0297_Sp_2023_EmblemHealth_Silver Premier
- Anthem Blue Access Gold EPO 30/55
- Anthem Blue Access Silver EPO 25/50
- Anthem Blue Access Silver EPO HSA 3000
- Anthem Connection Gold EPO 25/50
- Anthem Connection Gold EPO 30/55
- Anthem Connection Platinum EPO 20/40
- Anthem Connection Silver EPO 40/70
- Anthem Platinum EPO 5/25
- Anthem Silver EPO 40/70
- Anthem Silver EPO HSA 3000
- Oxford Liberty Bronze HSA 5750
- Oxford Liberty Gold 30/60 G
- Oxford Liberty Gold EPO 25/50 ZD
- Oxford Liberty Gold EPO 30/60
- Oxford Liberty Gold HSA 1500 M
- Oxford Liberty Platinum EPO
- Oxford Liberty Silver 30/60 G
- Oxford Liberty Silver 40/80
- Oxford Liberty Silver EPO 50/100 ZD
- Oxford Liberty Silver HSA 4000 M
- Oxford Metro Bronze HSA 7000 G
- Oxford Metro EPO 25/40
- Oxford Metro EPO 25/40 G
- Oxford Metro Silver EPO 30/80 G
- Oxford Metro Silver EPO 50/100 ZD
2022 SUMMARY OF BENEFITS AND COVERAGE (SBC)
- EmblemHealth Bridge Gold PPO
- EmblemHealth Bridge Gold Virtual
- EmblemHealth Bridge Platinum PPO
- EmblemHealth Milennium Bronze Premier G
- EmblemHealth Milennium Bronze Value G
- EmblemHealth Millennium Gold Virtual
- EmblemHealth Millennium Silver Value G
- EmblemHealth Prime Bronze HSA
- EmblemHealth Prime Gold Premier
- EmblemHealth Prime Gold Value
- EmblemHealth Prime Platinum Premier
- EmblemHealth Prime Silver HSA
- EmblemHealth Prime Silver Premier
- EmblemHealth Select Care Bronze Premier
- EmblemHealth Select Care Bronze Value
- EmblemHealth Select Care Gold Premier
- EmblemHealth Select Care Gold Value
- EmblemHealth Select Care Platinum Premier
- EmblemHealth Select Care Silver Premier
- EmblemHealth Select Care Silver Value
- Healthfirst Bonze 6850 Pro EPO HSA
- Healthfirst Bronze 5250 Pro EPO
- Healthfirst Bronze 8225 Pro
- Healthfirst Bronze Pro EPO HSA
- Healthfirst Platinum Pro EPO
- Healthfirst Silver 40/75/4700 Pro EPO
- Healthfirst Silver Pro EPO
- Heatlhfirst Gold 1350 Pro Plus EPO
- Oxford Liberty Bronze HSA 5750
- Oxford Liberty Gold 30/60 G
- Oxford Liberty Gold EPO 25/50 ZD
- Oxford Liberty Gold EPO 30/60
- Oxford Liberty Gold HSA 1500 Motion
- Oxford Liberty Platinum EPO
- Oxford Liberty Silver 25/50 G
- Oxford Liberty Silver EPO 40/70
- Oxford Liberty Silver EPO 50/100 ZD
- Oxford Liberty Silver HSA 4000 Motion
- Oxford Metro Bronze HSA 7000 G
- Oxford Metro Gold EPO 25/40
- Oxford Metro Gold EPO 25/40 G
- Oxford Metro Silver EPO 30/80 G
- Oxford Metro Silver EPO 50/100 ZD
2022 RESUMEN DE LA COBERTURA DE BENEFICIO (SBC)
- EmblemHealth Bridge Gold PPO
- EmblemHealth Bridge Gold Virtual
- EmblemHealth Bridge Platinum PPO
- EmblemHealth Millennium Bronze Premier G
- EmblemHealth Millennium Bronze Value G
- EmblemHealth Millennium Gold Virtual
- EmblemHealth Prime Bronze HSA
- EmblemHealth Prime Gold Premier
- EmblemHealth Prime Gold Value
- EmblemHealth Prime Platinum Premier
- EmblemHealth Prime Silver HSA
- EmblemHealth Prime Silver Premier
- EmblemHealth Select Care Bronze Premier
- EmblemHealth Select Care Bronze Value
- EmblemHealth Select Care Gold Premier
- EmblemHealth Select Care Gold Value
- EmblemHealth Select Care Platinum Premier
- EmblemHealth Select Care Silver Premier
- EmblemHealth Select Care Silver Value
- Healthfirst Bronze 5250 Pro EPO
- Healthfirst Bronze 6850 Pro EPO HSA
- Healthfirst Bronze 8225 Pro EPO
- Healthfirst Bronze Pro EPO HSA
- Healthfirst EPO Gold 1350 Pro Plus EPO
- Healthfirst Platinum Pro EPO
- Healthfirst Silver 40/75/4700 Pro EPO
- Healthfirst Silver Pro EPO
- Oxford Liberty Bronze HSA 5750
- Oxford Liberty Gold 30/60 G
- Oxford Liberty Gold EPO 25/50 ZD
- Oxford Liberty Gold EPO 30/60
- Oxford Liberty Gold HSA 1500 Motion
- Oxford Liberty Platinum EPO
- Oxford Liberty Silver EPO 25/50 G
- Oxford Liberty Silver EPO 40/70
- Oxford liberty Silver EPO 50/100 ZD
- Oxford Liberty Silver HSA 4000 Motion
- Oxford Metro Bronze HSA 7000 G
- Oxford Metro Gold 25/40
- Oxford Metro Gold EPO 25/40 G
- Oxford Metro Silver 30/80 G
- Oxford Metro Silver EPO 50/100 ZD
SUMMARY OF BENEFITS CARRIER HIGHLIGHTS (SOB)
ID CARDS
Medical
To view, print or request a new ID Card click on your carrier below. Need Help? Call 888.313.7277 for assistance.
EMBLEMHEALTH
To view and print an ID Card, you need to create an account and register with EmblemHealth. A Member ID number is required for registration.
ANTHEM
To view and print an ID Card, you need to create an account and register with Anthem. A Member ID number is required for registration
HEALTHFIRST
To view and print an ID Card, you need to create an account and register with Healthfirst. A Member ID number is required for registration.
OXFORD
To view and print your ID Card, you need to create an account and register with UnitedHealthcare. A member ID number and Group/Policy number OR the last 6 digits of the SS# and zip code are required.
DENTAL & VISION
To view, print or request a new ID Card click on your carrier below. Need Help? Call 888.313.7277 for assistance.
GUARDIAN
To view and print an ID card you, need to create an account and register with Guardian. A member SS# is required for registration.
SOLSTICE
To view and print your Solstice dental ID Card, you need the member date of birth, zip code and either SS# or ID Number.
To view and print your Solstice vision ID Card, you need to create an account register with DavisVision. A member ID Number, last name and date of birth are required.
UNITEDHEALTHCARE
To view and print your ID card, you need to create an account with UnitedHealthcare. A member ID number and Group/Policy number OR last 6 digits of the SS# are required. Sign into myuhcvision.com and choose Account Settings at the top right of the screen. You can request and print new ID cards.