Forms & Documents
Information and Guidelines
General Information
Enrollment and Network Information
Ancillary and Additional Products and Services
- Guardian Managed DentalGuard DHMO - Effective Prior to 3 Q 2020
- Guardian Managed DentalGuard DHMO - 3 Q 2020
- Guardian Managed DentalGuard DHMO Plus - Effective Prior to 3 Q 2020
- Guardian Managed DentalGuard DHMO Plus - 3 Q 2020
- Guardian DentalGuard Preferred PPO MAC
- Guardian DentalGuard Preferred PPO Plus MAC
- Solstice Dental EPO S800B - Effective Prior to 3 Q 2020
- Solstice Dental EPO S800B - 3 Q 2020
- Solstice Dental EPO S700B - Effective Prior to 3 Q 2020
- Solstice Dental EPO S700B - 3 Q 2020
- Solstice Dental PPO
- Solstice Dental Value PPO MAC
- UnitedHealthcare Select Managed Care - Effective Prior to 3 Q 2020
- UnitedHealthcare Select Managed Care - 3 Q 2020
- UnitedHealthcare INO 100/50/50 - Effective Prior to 3 Q 2020
- UnitedHealthcare INO 100/50/50 - 3 Q 2020
- UnitedHealthcare Low PPO MAC
- UnitedHealthcare High PPO MAC
- Guardian VisionGuard - Effective Prior to 3 Q 2020
- Guardian VisionGuard - 3 Q 2020
- Solstice Vision - Effective Prior to 3 Q 2020
- Solstice Vision - 3 Q 2020
- UnitedHealthcare Vision PPO - Effective Prior to 3 Q 2020
- UnitedHealthcare Vision PPO - 3 Q 2020
- EverGuard (Term Life, AD&D & Long Term Disability)
- EverGuard Plus (Term Life, AD&D & Long Term Disability)
- Guardian AccidentGuard Adv
- InfoArmor - PrivacyArmor & PrivacyArmor Plus
- LifeLock - Benefit Elite & Ultimate Plus™
- COBRA
- Health Advocate
- POP Kit Section 125
Reimbursement Forms
Carrier Prescription Lists
Broker Appointment Paperwork
Enrollment Forms
Enrollment materials
- Medical Waiver Form
- 3rd Quarter 2021 Enrollment Change Form
- 2nd Quarter 2021 Enrollment Change Form
- 1st Quarter 2021 Enrollment Change Form
- 4th Quarter 2020 Enrollment Change Form
- 3rd Quarter 2020 Enrollment Change Form
- Notice of Election 2021
- Common Law Employee Attestation Form
- Employer - EFT/ACH Form
- Group Attestation Form
- Small Employer Exception Certification
- Member Authorization Form
- Independent Contractor Attestation Form
- Domestic Partner Affidavit
- EverGuard and EverGuard Plus Late Enrollment Form
- AccidentGuard Adv Late Enrollment Form
- Allstate Identity Protection Late Enrollment Form
- LifeLock Late Enrollment Form
- EE Census Information Template
- New Group COBRA Member/Takeover Form
- PEO Employer Questionaire
Summary of Benefits
2021 Summary of Benefits and Coverage (SBC)
- EmblemHealth Prime Platinum PPO
- EmblemHealth Prime Platinum Premier
- EmblemHealth Select Care Platinum Premier
- Healthfirst Platinum Pro EPO
- Oxford Liberty Platinum EPO
- EmblemHealth Prime Gold PPO
- EmblemHealth Prime Gold Premier
- EmblemHealth Prime Gold Virtual
- EmblemHealth Select Care Gold Premier
- EmblemHealth Select Care Gold Value
- EmblemHealth Millennium Gold Virtual
- Healthfirst Gold Pro EPO
- Healthfirst Gold 25/50/0 Pro EPO
- Oscar Circle Gold 2000
- Oxford Metro Gold EPO 25/40 G
- Oxford Metro Gold EPO 25/40
- Oxford Liberty Gold 30/60
- Oxford Liberty Gold 30/60 G
- Oxford Liberty Gold 25/50 ZD
- Oxford Liberty Gold HSA 1500 Motion
- EmblemHealth Prime Silver Premier
- EmblemHealth Select Care Silver Premier
- EmblemHealth Select Care Silver Value
- EmblemHealth Millennium Silver Value G
- EmblemHealth Prime Silver HSA
- Healthfirst Silver Pro EPO
- Healthfirst Silver 40/75/4700 Pro EPO
- Oscar Circle Silver 5000
- Oxford Metro Silver EPO 30/80 G
- Oxford Metro Silver EPO 50/100 ZD
- Oxford Liberty Silver EPO 25/50
- Oxford Liberty Silver EPO 40/70
- Oxford Liberty Silver HSA 4000 Motion
- EmblemHealth Prime Bronze HSA
- EmblemHealth Select Care Bronze Premier
- EmblemHealth Select Care Bronze Value
- EmblemHealth Millennium Bronze Premier G
- EmblemHealth Millennium Bronze Value G
- Healthfirst Bronze Pro EPO HSA
- Healthfirst Bronze 6850 Pro EPO HSA
- Healthfirst Bronze 8150 Pro EPO
- Oscar Circle Bronze 4500
- Oxford Metro Bronze HSA 7000 G
- Oxford Liberty Bronze HSA 5750
2020 Summary of Benefits and Coverage (SBC)
- EmblemHealth Prime Platinum POS
- EmblemHealth Prime Platinum Premier
- EmblemHealth Select Care Platinum Premier
- Healthfirst Platinum Pro EPO
- Oscar Circle Platinum 2
- Oscar Circle Plus Platinum 2
- Oscar Circle Platinum 1
- Oscar Circle Plus Platinum 1
- Oxford Liberty Platinum EPO 40/80 411
- EmblemHealth Prime Gold POS
- EmblemHealth Prime Gold Premier
- EmblemHealth Select Care Gold Premier
- Healthfirst Gold Pro EPO
- Healthfirst Gold 25/50/0 Pro EPO
- Oscar Circle Gold
- Oscar Circle Plus Gold
- Oscar Circle Gold 1000
- Oscar Circle Plus Gold 1000
- Oscar Circle Gold 1250
- Oscar Circle Plus Gold 1250
- Oscar Circle Gold 2000
- Oscar Circle Plus Gold 2000
- Oxford Liberty Gold EPO 25/50 ZD
- Oxford Liberty Gold EPO 30/60 G
- Oxford Liberty Gold EPO 30/60
- Oxford Metro Gold EPO 25/40
- Oxford Metro Gold EPO 25/40 G
- EmblemHealth Prime Silver Premier
- EmblemHealth Select Care Silver Premier
- EmblemHealth Select Care Silver Value
- EmblemHealth Millennium Silver Value G
- EmblemHealth Prime Silver HSA
- Healthfirst Silver Pro EPO
- Healthfirst Silver 40/75/4700 Pro EPO
- Oscar Circle Silver
- Oscar Circle Plus Silver
- Oscar Circle Silver 3000
- Oscar Circle Plus Silver 3000
- Oscar Circle Silver 4500
- Oscar Circle Plus Silver 4500
- Oscar Circle Silver HSA 3000
- Oscar Circle Plus Silver HSA 3000
- Oxford Metro Silver EPO 30/80 G
- Oxford Metro Silver EPO 50/100 ZD
- Oxford Liberty Silver EPO 40/70
- Oxford Liberty Silver EPO 25/50 G
- EmblemHealth Prime Bronze HSA
- EmblemHealth Select Care Bronze Premier
- EmblemHealth Select Care Bronze Value
- EmblemHealth Millennium Bronze Pemier G
- EmblemHealth Millennium Bronze Value G
- Healthfirst Bronze Pro EPO HSA
- Healthfirst Bronze 6650 Pro EPO HSA
- Healthfirst Bronze 8150 Pro EPO
- Oscar Circle Bronze 4500
- Oscar Circle Plus Bronze 4500
- Oscar Circle Bronze 8150
- Oscar Circle Plus Bronze 8150
- Oscar Circle Bronze HSA 6750
- Oscar Circle Plus Bronze HSA 6750
- Oxford Liberty Bronze EPO HSA 4000
- Oxford Metro Bronze EPO HSA 6750 G
2020 Resumen De La Cobertura De Beneficio (SBC)
- EmblemHealth Prime Platinum POS
- EmblemHealth Prime Platinum Premier
- EmblemHealth Select Care Platinum Premier
- Healthfirst Platinum Pro EPO
- Oscar Circle Platinum 2
- Oscar Circle Plus Platinum 2
- Oscar Circle Platinum 1
- Oscar Circle Plus Platinum 1
- Oxford LIberty Platinum EPO 40/80 411
- EmblemHealth Prime Gold POS
- EmblemHealth Prime Gold Premier
- EmblemHealth Select Care Gold Premier
- Healthfirst Gold Pro EPO
- Healthfirst Gold 25/50/0 Pro EPO
- Oscar Circle Gold
- Oscar Circle Plus Gold
- Oscar Circle Plus Gold
- Oscar Circle Gold 1000
- Oscar Circle Plus Gold 1000
- Oscar Circle Gold 1250
- Oscar Circle Plus Gold 1250
- Oscar Circle Gold 2000
- Oscar Circle Plus Gold 2000
- Oxford LIberty Gold EPO 25/50 ZD
- Oxford Liberty Gold EPO 30/60 G
- Oxford Liberty Gold EPO 30/60
- Oxford Metro Gold EPO 25/40
- Oxford Metro Gold EPO 25/40 G
- EmblemHealth Prime Silver Premier
- EmblemHealth Select Care Silver Premier
- EmblemHealth Select Care Silver Value
- EmblemHealth Select Care Silver Value G
- EmblemHealth Prime Silver HSA
- Healthfirst Silver Pro EPO
- Healthfirst Silver 40/75/4700 Pro EPO
- Oscar Circle Silver
- Oscar Circle Plus Silver
- Oscar Circle Silver 3000
- Oscar Circle Plus Silver 3000
- Oscar Circle Silver 4500
- Oscar Circle Plus Silver 4500
- Oscar Circle Silver HSA 3000
- Oscar Circle Plus Silver HSA 3000
- Oxford Metro Silver PEO 50/100 ZD
- Oxford Liberty Silver EPO 40/70
- Oxford Liberty Silver EPO 25/50 G
- Oxford Metro Silver EPO 30/80 G
- EmblemHealth Prime Bronze HSA
- EmblemHealth Select Care Bronze Premier
- EmblemHealth Select Care Bronze Value
- EmblemHealth Millennium Bronze Premier G
- EmblemHealth Millennium Bronze Value G
- Healthfirst Bronze Pro EPO HSA
- Healthfirst Bronze 6650 Pro EPO HSA
- Healthfirst Bronze 8150 Pro EPO
- Oscar Circle Plus Bronze 4500
- Oscar Circle Bronze 8150
- Oscar Circle Plus Bronze 8150
- OScar Circle Bronze HSA 6750
- Oscar Circle Plus Bronze 6750
- Oxford LIberty Bronze EPO HSA 4000
- Oxford Metro Bronze EPO HSA 6750 G
Summary of Benefits Carrier Highlights (SOB)
ID CARDS
Medical
To print or request a new ID card click on your carrier below. Need Help? Call 888.313.7277 for assistance.
EmblemHealth
A Member ID number is required when printing a temporary ID Card.
Healthfirst
A Member ID number is required when printing a temporary ID Card.
Oscar
A Member ID number is required when printing a temporary ID Card.
Oxford
A Member ID number is required when printing a temporary ID Card.
Dental & Vision
To print or request a new ID card click on your carrier below. Need Help? Call 888.313.7277 for assistance.
Guardian
A Member SS# or ID Number is required when printing a temporary ID Card.
Solstice
To view and print your Solstice dental ID Card you will need your SS# or ID Number.
To view and print your Solstice vision ID Card you will need your SS# or ID Number.
UnitedHealthcare
A member SS# and zip code is needed to create an account. Sign into myuhcvision.com and choose Account Settings at the top right of the screen. You can request and print new ID cards.