Forms & Documents
Information and Guidelines
GENERAL INFORMATION
ENROLLMENT AND NETWORK INFORMATION
ANCILLARY AND ADDITIONAL PRODUCTS AND SERVICES
- Allstate Identity Protection
- COBRA
- EverGuard (Term Life, AD&D & Long Term Disability)
- EverGuard Plus (Term Life, AD&D & Long Term Disability)
- Guardian AccidentGuard Adv
- Guardian Byte
- Guardian DentalGuard Preferred PPO MAC
- Guardian DentalGuard Preferred PPO Plus MAC
- Guardian Managed DentalGuard DHMO
- Guardian Managed DentalGuard DHMO Plus
- Guardian VisionGuard
- Health Advocate
- LifeLock - Benefit Elite & Ultimate Plus™
- OCA - FSA & Commuter Benefits
- Pet Plan
- Pet Plan FAQ
- Section 125 Pop Kit
- Solstice Dental EPO S700B
- Solstice Dental EPO S800B
- Solstice Dental PPO
- Solstice Dental Value PPO MAC
- Solstice Vision
- UnitedHealthcare High PPO MAC
- UnitedHealthcare INO 100/50/50
- UnitedHealthcare Low PPO MAC
- UnitedHealthcare Select Managed Care
- UnitedHealthcare SmileDirectClub
- UnitedHealthcare Vision PPO
REIMBURSEMENT FORMS
CARRIER PRESCRIPTION LISTS
AGENT/BROKER CREDENTIALING
Enrollment Forms
ENROLLMENT MATERIALS
- 2022 Notice of Election (Group Application)
- AccidentGuard Adv Late Enrollment Form
- Allstate Identity Protection Late Enrollment Form
- Common Law Employee Attestation Form
- Domestic Partner Affidavit
- EE Census Information Template
- Employer - EFT/ACH Form
- EverGuard and EverGuard Plus Late Enrollment Form
- Gradient Employee Level RPT Census Converter
- Group Attestation Form
- Guardian Conversion Form
- LifeLock Late Enrollment Form
- Member Authorization Form
- New Group COBRA Member/Takeover Form
- OCA Late Enrollment Form
- Open Enrollment Email Template
- PEO Employer Questionnaire
- Pet Plan Late Enrollment Form
- Small Employer Exception Certification
ENROLLMENT CHANGE FORMS
- 1st Quarter 2022 Enrollment Change Form
- 2nd Quarter 2022 Enrollment Change Form
- 3rd Quarter 2022 Enrollment Change Form (New Business Only)
- 3rd Quarter 2022 Enrollment Change Form (Renewal Only)
- 4th Quarter 2021 Enrollment Change Form
- 4th Quarter 2022 Enrollment Change Form (New Business Only)
- 4th Quarter 2022 Enrollment Change Form (Renewal Only)
Renewal Forms
RENEWALS
- EmblemHealth 2023 Prior Approval Letters
- Healthfirst 2023 Prior Approval Letters
- HealthPass Employee Open Enrollment Instructions
- HealthPass Employer Open Enrollment Instructions
- HealthPass GA and Broker Open Enrollment Instructions
- HealthPass Online Portal (HOP) Renewal Walkthrough
- How to Manage your Benefits
- Oxford 2023 Prior Approval Letters
- Renewing Group Application 2022
- Renewing Group Attestation Form
- Renewing Group Mapping 1 Quarter through 3 Quarter 2022
- Renewing Group Mapping 4th Quarter 2022
Summary of Benefits
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 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 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
2021 SUMMARY OF BENEFITS AND COVERAGE (SBC)
- EmblemHealth Millennium Bronze Premier G
- EmblemHealth Millennium Bronze Value G
- EmblemHealth Millennium Gold Virtual
- EmblemHealth Millennium Silver Value G
- EmblemHealth Prime Bronze HSA
- EmblemHealth Prime Gold PPO
- EmblemHealth Prime Gold Premier
- EmblemHealth Prime Gold Virtual
- EmblemHealth Prime Platinum PPO
- 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 6850 Pro EPO HSA
- Healthfirst Bronze 8150 Pro EPO
- Healthfirst Bronze Pro EPO HSA
- Healthfirst Gold 25/50/0 Pro EPO
- Healthfirst Gold Pro EPO
- Healthfirst Platinum Pro EPO
- Healthfirst Silver 40/75/4700 Pro EPO
- Healthfirst Silver Pro EPO
- Oscar Circle Bronze 4500
- Oscar Circle Gold 2000
- Oscar Circle Silver 5000
- Oxford Liberty Bronze HSA 5750
- Oxford Liberty Gold 25/50 ZD
- Oxford Liberty Gold 30/60
- Oxford Liberty Gold 30/60 G
- 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 EPO 25/40
- Oxford Metro Gold EPO 25/40 G
- Oxford Metro Silver EPO 30/80 G
- Oxford Metro Silver EPO 50/100 ZD
2021 RESUMEN DE LA COBERTURA DE BENEFICIO (SBC)
- EmblemHealth Millennium Bronze Premier G
- EmblemHealth Millennium Bronze Value G
- EmblemHealth Millennium Gold Virtual
- EmblemHealth Millennium Silver Value G
- EmblemHealth Prime Bronze HSA
- EmblemHealth Prime Gold PPO
- EmblemHealth Prime Gold Premier
- EmblemHealth Prime Gold Virtual
- EmblemHealth Prime Platinum PPO
- EmblemHealth Prime Platinum Premier
- EmblemHealth Prime Platinum Premier
- 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 6850 Pro EPO HSA
- Healthfirst Bronze 8150 Pro EPO
- Healthfirst Bronze Pro EPO HSA
- Healthfirst Gold Pro EPO
- Healthfirst Platinum Pro EPO
- Healthfirst Silver Pro EPO
- Oxford Liberty Bronze HSA 5750
- Oxford Liberty Gold HSA 1500 Motion
- Oxford Liberty Platinum EPO
- Oxford Liberty Silver HSA 4000 Motion
- Oxford Metro Bronze HSA 7000 G
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.
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.
OSCAR
To view and print an ID Card, you need to create an account and register with Oscar. 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.