Brokers:
Individual Plans

Forms

• Online search
• Active&Fit Fitness Benefit
• Member Guidebook
• Premium Payment Options
• Pediatric dental benefits
• Pediatric vision benefits

2021 plans:

• Comparison of Benefits

• 5 Tier Commercial Metal:
  Annual Notice of Change
  Online Search | PDF
  Prior Authorization and Step Therapy Criteria
• 5 Tier Commercial:
  Annual Notice of Change
  Online Search | PDF
  Prior Authorization and Step Therapy Criteria
• 3 Tier Commercial:
  Annual Notice of Change
  Online Search | PDF
  Prior Authorization and Step Therapy Criteria
• Application (PDF)
• Application (PDF) Spanish
• Change/termination form (PDF)
• Change/termination form (Spanish)
• Summaries of Benefits and Coverage (SBCs)

2022 plans:

• Comparison of Benefits
• 5 Tier Commercial Metal:
  Online Search | PDF
• Application (English)
• Application (Spanish)
• Change/termination form (PDF)
• Change/termination form (Spanish)
• Summaries of Benefits and Coverage (SBCs)

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Last Updated: 1/10/2022