Anthem Blue Cross

Form Name	Effective Date	Download Form
New Group Submission
New Bustiness Submission Checklist	08/01/2022	Download
Employer Application - All Lines 1.23	01/01/2023	Download
Employer Application - All Lines 1.22	01/01/2022	Download
Employer Application - Medical & Dental Only 1.21	01/01/2021	Download
Electronic Funds Transfer Authorization - Initial & Recurring Payment Options	12/01/2022	Download
Proprietor/Partner/Corporate Officer Eligibility Statement	12/01/2022	Download
Conditions of Enrollment Start Up Companies PEO Spin Offs	01/01/2020	Download
Group Size Attestation Form	01/01/2020	Download
Group Size Attestation Form 1.22	01/01/2022	Download
Instructions - Group Size Attestation Form	01/01/2020	Download
Act Wise HSA Small Group Questionnaire 1.20	01/01/2020	Download
POP Brochure and Application	01/01/2020	Download
In Force Group Forms
Authorization Request by Phone for Electronic Check/ACH	01/01/2020	Download
Cal-Cobra, Cobra and Medicare Survey Form	12/01/2022	Download
Employer Information Change Form	01/01/2020	Download
Group Renewal Plan Change Request Form 1.21	01/01/2021	Download
Internet Eligibility Agreement	01/01/2020	Download
Reinstatement Electronic Debit Form	01/01/2020	Download
Request for Group Life Conversion Information	01/01/2020	Download
Specialty Benefit Modification Form (for existing groups adding or changing specialty coverage)	01/01/2020	Download
Administration
Employer Group Administrator Manual	01/01/2022	Download
EmployerAccess for Online Benefits Management	01/01/2022	Download
Employer Contact Sheet - Where to Go!	01/01/2022	Download

Form Name	Effective Date	Download Form
Enrollment and Change Forms
Employee Application 1.23	01/01/2023	Download
Employee Application 1.22	01/01/2022	Download
Employee Waiver Form 1.22	12/01/2022	Download
Employee Social Security Number Exception Request Form	01/01/2020	Download
Custodial Verification Form	01/01/2020	Download
Handicapped Dependent Certification Form	01/01/2020	Download
Parent-Child Relationship Certification Form	01/01/2020	Download
Transition of Care Policy	01/01/2020	Download
Continuity of Care/Transition of Care Request Form	01/01/2020	Download
Continuity of Care/Transition of Care Request Form - Spanish	01/01/2020	Download
Claim Forms
Member Authorization (HIPAA) Form	01/01/2020	Download
Member Authorization (HIPAA) Form - Spanish	01/01/2020	Download
Medical Claim Form	01/01/2020	Download
Dental Claim Form	01/01/2020	Download
Life Claim Form	01/01/2020	Download
Pharmacy Claim Form	01/01/2020	Download
Pharmacy Prior Authorization Form	01/01/2020	Download
Vision Claim Form	01/01/2020	Download

Form Name	Effective Date	Download Form
2023 Medical HMO
CaliforniaCare Full HMO Network
Platinum HMO 0 20 6RJ6	01/01/2023	Summary	SBC
Platinum HMO 0 25 6RH3	01/01/2023	Summary	SBC
Platinum HMO 0 30 6RG1	01/01/2023	Summary	SBC
Gold HMO 30 6RH8	01/01/2023	Summary	SBC
Gold HMO 35 6RHZ	01/01/2023	Summary	SBC
Gold HMO 35 500 20% 6RGA	01/01/2023	Summary	SBC
Gold HMO 35 1250 20% 6RHC	01/01/2023	Summary	SBC
Silver HMO 55 6RJG	01/01/2023	Summary	SBC
Silver HMO 60 2500 45% 6RHM	01/01/2023	Summary	SBC
Select HMO Network
Platinum Select HMO 0 20 6RHH	01/01/2023	Summary	SBC
Platinum Select HMO 0 25 6RHW	01/01/2023	Summary	SBC
Platinum Select HMO 0 30 6RGP	01/01/2023	Summary	SBC
Gold Select HMO 30 6RJ4	01/01/2023	Summary	SBC
Gold Select HMO 35 6RH0	01/01/2023	Summary	SBC
Gold Select HMO 35 500 20% 6RK2	01/01/2023	Summary	SBC
Gold Select HMO 35 1250 20% 6RJW	01/01/2023	Summary	SBC
Silver Select HMO 55 6RHQ	01/01/2023	Summary	SBC
Silver Select HMO 60 2500 45% 6RHB	01/01/2023	Summary	SBC
Silver Select HMO 60 2500 45% WH 6RFX - Whole Health	01/01/2023	Summary	SBC
Priority Select HMO Network
Platinum Priority Select HMO 0 20 6RHG	01/01/2023	Summary	SBC
Platinum Priority Select HMO 0 25 6RG3	01/01/2023	Summary	SBC
Platinum Priority Select HMO 0 30 6RG4	01/01/2023	Summary	SBC
Gold Priority Select HMO 30 6RGG	01/01/2023	Summary	SBC
Gold Priority Select HMO 35 6RJ3	01/01/2023	Summary	SBC
Gold Priority Select HMO 35 500 20% 6RGQ	01/01/2023	Summary	SBC
Gold Priority Select HMO 35 1250 20% 6RG0	01/01/2023	Summary	SBC
Silver Priority Select HMO 55 6RK5	01/01/2023	Summary	SBC
Silver Priority Select HMO 60 2500 45% 6RFS	01/01/2023	Summary	SBC
Silver Priority Select HMO 60 2500 45% WH 6RJH - Whole Health	01/01/2023	Summary	SBC
Vivity Network
Link Platinum Vivity HMO 15 6RG8	01/01/2023	Summary	SBC
Link Platinum Vivity HMO 15 WH 6RGN - Whole Health	01/01/2023	Summary	SBC
Link Gold Vivity HMO 25 6RJZ	01/01/2023	Summary	SBC
Link Gold Vivity HMO 25 WH 6RJR - Whole Health	01/01/2023	Summary	SBC
Link Gold Vivity HMO 25 500 6RHV	01/01/2023	Summary	SBC
Link Gold Vivity HMO 25 500 WH 6RGL - Whole Health	01/01/2023	Summary	SBC
Link Gold Vivity HMO 35 1000 6RGJ	01/01/2023	Summary	SBC
Link Gold Vivity HMO 35 1000 WH 6RFW - Whole Health	01/01/2023	Summary	SBC
Link Gold Vivity HMO 35 1850 6RK7	01/01/2023	Summary	SBC
Link Gold Vivity HMO 35 1850 WH 6RGM - Whole Health	01/01/2023	Summary	SBC
Link Silver Vivity HMO 50 2650 6RG2	01/01/2023	Summary	SBC
Link Silver Vivity HMO 50 2650 WH 6RFZ - Whole Health	01/01/2023	Summary	SBC
2023 Medical PPO
Prudent Buyer Full PPO Network (BlueCard Network Out-of-State)
Platinum PPO 15 40 10% 6RH4	01/01/2023	Summary	SBC
Platinum PPO 5 200 15% 6RJP	01/01/2023	Summary	SBC
Platinum PPO 5 200 15% WH 6RFQ - Whole Health	01/01/2023	Summary	SBC
Platinum PPO 15 250 10% 6RG6	01/01/2023	Summary	SBC
Gold PPO 25 30% 6RFN	01/01/2023	Summary	SBC
Gold PPO 30 500 20% 6RG9	01/01/2023	Summary	SBC
Gold PPO 35 500 25% 6RGV	01/01/2023	Summary	SBC
Gold PPO 35 500 25% WH 6RJA - Whole Health	01/01/2023	Summary	SBC
Gold PPO 30 750 20% 6RGS	01/01/2023	Summary	SBC
Gold PPO 35 1000 20% 6RH1	01/01/2023	Summary	SBC
Gold PPO 35 1000 20% WH 6RK3 - Whole Health	01/01/2023	Summary	SBC
Gold PPO 5 1500 30% 6RK1	01/01/2023	Summary	SBC
Gold PPO 1700 15% w HSA PrevRx 6SLF (Individual Contract)	01/01/2023	Summary	SBC
Gold PPO 1700 15% w HSA PrevRx 6SLD (Family Contract)	01/01/2023	Summary	SBC
Silver PPO 45 1750 40% 6RGX	01/01/2023	Summary	SBC
Silver PPO 45 1750 40% WH 6RGZ - Whole Health	01/01/2023	Summary	SBC
Silver PPO 50 2200 40% 6RK6	01/01/2023	Summary	SBC
Silver PPO 55 1950 35% 6RJ0	01/01/2023	Summary	SBC
Silver PPO 55 2500 45% 6RFY	01/01/2023	Summary	SBC
Silver PPO 55 2500 45% WH 6RGE - Whole Health	01/01/2023	Summary	SBC
Silver PPO 2100 30% w HSA PrevRx 6RK0 (Individual Contract)	01/01/2023	Summary	SBC
Silver PPO 2100 30% w HSA PrevRx 6RJ5 (Family Contract)	01/01/2023	Summary	SBC
Silver PPO 2600 35% w HSA PrevRx 6RG5 (Individual Contract)	01/01/2023	Summary	SBC
Silver PPO 2600 35% w HSA PrevRx 6RH6 (Family Contract)	01/01/2023	Summary	SBC
Bronze PPO 4600 50% 6RJX	01/01/2023	Summary	SBC
Bronze PPO 40 6200 40% 6RJN	01/01/2023	Summary	SBC
Bronze PPO 60 6850 40% 6RK4	01/01/2023	Summary	SBC
Bronze PPO 70 6600 35% 6RFV	01/01/2023	Summary	SBC
Bronze PPO 75 7300 40% 6RJ1	01/01/2023	Summary	SBC
Bronze PPO 6000 45% w HSA PrevRx 6RJK	01/01/2023	Summary	SBC
Bronze PPO 6000 45% w HSA PrevRx WH 6RGR - Whole Health	01/01/2023	Summary	SBC
Bronze PPO 6700 0% w HSA PrevRx 6RG7	01/01/2023	Summary	SBC
Bronze PPO 6700 0% w HSA PrevRx WH 6RJB - Whole Health	01/01/2023	Summary	SBC
Select PPO Network (BlueCard Network Out-of-State)
Platinum Select PPO 15 40 10% 6RHY	01/01/2023	Summary	SBC
Platinum Select PPO 15 10% 6RJJ	01/01/2023	Summary	SBC
Platinum Select PPO 5 200 15% 6RJT	01/01/2023	Summary	SBC
Platinum Select PPO 15 250 10% 6RHD	01/01/2023	Summary	SBC
Gold Select PPO 25 30% 6RGD	01/01/2023	Summary	SBC
Gold Select PPO 25 350 20% 6RGH	01/01/2023	Summary	SBC
Gold Select PPO 30 500 20% 6RHX	01/01/2023	Summary	SBC
Gold Select PPO 35 500 25% 6RH7	01/01/2023	Summary	SBC
Gold Select PPO 30 750 20% 6RFP	01/01/2023	Summary	SBC
Gold Select PPO 35 1000 20% 6RFM	01/01/2023	Summary	SBC
Gold Select PPO 5 1500 30% 6RJD	01/01/2023	Summary	SBC
Gold Select PPO 1700 15% w HSA PrevRx 6SLC (Individual Contract)	01/01/2023	Summary	SBC
Gold Select PPO 1700 15% w HSA PrevRx 6SLE (Family Contract)	01/01/2023	Summary	SBC
Silver Select PPO 45 1750 40% 6RGW	01/01/2023	Summary	SBC
Silver Select PPO 45 1750 40% WH 6RJE - Whole Health	01/01/2023	Summary	SBC
Silver Select PPO 50 2200 40% 6RJF	01/01/2023	Summary	SBC
Silver Select PPO 55 1950 35% 6RHJ	01/01/2023	Summary	SBC
Silver Select PPO 55 2500 35% 6RFU	01/01/2023	Summary	SBC
Silver Select PPO 55 2500 45% 6RGB	01/01/2023	Summary	SBC
Silver Select PPO 2100 30% w HSA PrevRx 6RJ2 (Individual Contract)	01/01/2023	Summary	SBC
Silver Select PPO 2100 30% w HSA PrevRx 6RHT (Family Contract)	01/01/2023	Summary	SBC
Silver Select PPO 2600 35% w HSA PrevRx 6RJM (Individual Contract)	01/01/2023	Summary	SBC
Silver Select PPO 2600 35% w HSA PrevRx 6RHL (Family Contract)	01/01/2023	Summary	SBC
Bronze Select PPO 4600 50% 6RH9	01/01/2023	Summary	SBC
Bronze Select PPO 40 6200 40% 6RJS	01/01/2023	Summary	SBC
Bronze Select PPO 60 6850 40% 6RHK	01/01/2023	Summary	SBC
Bronze Select PPO 70 6600 35% 6RFR	01/01/2023	Summary	SBC
Bronze Select PPO 75 7300 40% 6RGT	01/01/2023	Summary	SBC
Bronze Select PPO 6000 45% w HSA PrevRx 6RJU	01/01/2023	Summary	SBC
Bronze Select PPO 6700 0% w HSA PrevRx 6RJV	01/01/2023	Summary	SBC
Bronze Select PPO 7000 0% w HSA 6RHP	01/01/2023	Summary	SBC
2022 Medical HMO
CaliforniaCare Full HMO Network
Platinum HMO 0/20 (6BUW)	01/01/2022	Summary	SBC
Platinum HMO 0/25 (6BT2)	01/01/2022	Summary	SBC
Platinum HMO 0/30 (6BRB)	01/01/2022	Summary	SBC
Gold HMO 30 (6BN0)	01/01/2022	Summary	SBC
Gold HMO 35 (6BUH)	01/01/2022	Summary	SBC
Gold HMO 35/1250/20% (6BM6)	01/01/2022	Summary	SBC
Gold HMO 35/700/20% (6BLQ)	01/01/2022	Summary	SBC
Silver HMO 55 (6BQZ)	01/01/2022	Summary	SBC
Silver HMO 60/2500/45% (6BRT)	01/01/2022	Summary	SBC
Select HMO Network
Platinum Select HMO 0/20 (6BWS)	01/01/2022	Summary	SBC
Platinum Select HMO 0/25 (6BSY)	01/01/2022	Summary	SBC
Platinum Select HMO 0/30 (6BRF)	01/01/2022	Summary	SBC
Gold Select HMO 30 (6BMW)	01/01/2022	Summary	SBC
Gold Select HMO 35 (6BUD)	01/01/2022	Summary	SBC
Gold Select HMO 35/1250/20% (6BMA)	01/01/2022	Summary	SBC
Gold Select HMO 35/700/20% (6BLU)	01/01/2022	Summary	SBC
Silver Select HMO 55 (6BR3)	01/01/2022	Summary	SBC
Silver Select HMO 60/2500/45% (6BRP)	01/01/2022	Summary	SBC
Silver Select HMO 60/2500/45% WH (6BWJ) - Whole Health	01/01/2022	Summary	SBC
Priority Select HMO Network
Platinum Priority Select HMO 0/20 (6BWW)	01/01/2022	Summary	SBC
Platinum Priority Select HMO 0/25 (6BT6)	01/01/2022	Summary	SBC
Platinum Priority Select HMO 0/30 (6BRK)	01/01/2022	Summary	SBC
Gold Priority Select HMO 30 (6BN4)	01/01/2022	Summary	SBC
Gold Priority Select HMO 35 (6BUM)	01/01/2022	Summary	SBC
Gold Priority Select HMO 35/1250/20% (6BM2)	01/01/2022	Summary	SBC
Gold Priority Select HMO 35/700/20% (6BLY)	01/01/2022	Summary	SBC
Silver Priority Select HMO 55 (6BR7)	01/01/2022	Summary	SBC
Silver Priority Select HMO 60/2500/45% (6BRX)	01/01/2022	Summary	SBC
Silver Priority Select HMO 60/2500/45% WH (6BWN) - Whole Health	01/01/2022	Summary	SBC
Vivity Network
Link Platinum Vivity HMO 15 (6BV0)	01/01/2022	Summary	SBC
Link Platinum Vivity HMO 15 WH (6BV4) - Whole Health	01/01/2022	Summary	SBC
Link Gold Vivity HMO 25 (6BVU)	01/01/2022	Summary	SBC
Link Gold Vivity HMO 25 WH (6BVQ) - Whole Health	01/01/2022	Summary	SBC
Link Gold Vivity HMO 25/500 (6BW6)	01/01/2022	Summary	SBC
Link Gold Vivity HMO 25/500 WH (6BWA) - Whole Health	01/01/2022	Summary	SBC
Link Gold Vivity HMO 35/1000 (6BV8)	01/01/2022	Summary	SBC
Link Gold Vivity HMO 35/1000 WH (6BVC) - Whole Health	01/01/2022	Summary	SBC
Link Gold Vivity HMO 35/1750 (6BVG)	01/01/2022	Summary	SBC
Link Gold Vivity HMO 35/1750 WH (6BVL) - Whole Health	01/01/2022	Summary	SBC
Link Silver Vivity HMO 50/2250 (6BVY)	01/01/2022	Summary	SBC
Link Silver Vivity HMO 50/2250 WH (6BW2) - Whole Health	01/01/2022	Summary	SBC
2022 Medical EPO
Prudent Buyer Full PPO Network (BlueCard Network Out-of-State)
Gold EPO 35/500/20% (6BMN)	01/01/2022	Summary	SBC
Gold EPO 35/1700/20% (6BMS)	01/01/2022	Summary	SBC
2022 Medical PPO
Prudent Buyer Full PPO Network (BlueCard Network Out-of-State)
Platinum PPO 15/40/10% (6BNC)	01/01/2022	Summary	SBC
Platinum PPO 5/250/15% (6BL4)	01/01/2022	Summary	SBC
Platinum PPO 5/250/15% WH (6BLC) - Whole Health	01/01/2022	Summary	SBC
Platinum PPO 15/250/10% (6BPB)	01/01/2022	Summary	SBC
Gold PPO 25/30% (6BNT)	01/01/2022	Summary	SBC
Gold PPO 30/500/20% (6BP1)	01/01/2022	Summary	SBC
Gold PPO 35/500/25% (6BK6)	01/01/2022	Summary	SBC
Gold PPO 35/500/25% WH (6BKE) - Whole Health	01/01/2022	Summary	SBC
Gold PPO 30/750/20% (6BPT)	01/01/2022	Summary	SBC
Gold PPO 35/1000/20% (6BQ1)	01/01/2022	Summary	SBC
Gold PPO 35/1000/20% WH (6BQ9) - Whole Health	01/01/2022	Summary	SBC
Gold PPO 5/1500/30% (6BLG)	01/01/2022	Summary	SBC
Silver PPO 45/1750/40% (6BQD)	01/01/2022	Summary	SBC
Silver PPO 45/1750/40% WH (6BQM) - Whole Health	01/01/2022	Summary	SBC
Silver PPO 55/1950/35% (6BQV)	01/01/2022	Summary	SBC
Silver PPO 50/2200/40% (6BPK)	01/01/2022	Summary	SBC
Silver PPO 55/2500/45% (6BKJ)	01/01/2022	Summary	SBC
Silver PPO 55/2500/45% WH (6BKS) - Whole Health	01/01/2022	Summary	SBC
Silver PPO 2100/30% w/HSA PrevRx (6BNP/6BU0)	01/01/2022	Summary	SBC
Silver PPO 2600/35% w/HSA PrevRx (6BJE/6BJN)	01/01/2022	Summary	SBC
Bronze PPO 4600/50% (6BKW)	01/01/2022	Summary	SBC
Bronze PPO 40/6200/40% (6BU4)	01/01/2022	Summary	SBC
Bronze PPO 70/6600/35% (6BUR)	01/01/2022	Summary	SBC
Bronze PPO 60/6850/40% (6BME)	01/01/2022	Summary	SBC
Bronze PPO 75/7300/40% (6BJW)	01/01/2022	Summary	SBC
Bronze PPO 6000/45% w/HSA PrevRx (6BS7)	01/01/2022	Summary	SBC
Bronze PPO 6000/45% w/HSA PrevRx WH (6BSF) - Whole Health	01/01/2022	Summary	SBC
Bronze PPO 6700/0% w/HSA PrevRx (6BSK)	01/01/2022	Summary	SBC
Bronze PPO 6700/0% w/HSA PrevRx WH (6BST) - Whole Health	01/01/2022	Summary	SBC
Select PPO Network (BlueCard Network Out-of-State)
Platinum Select PPO 15/10% (6BTJ)	01/01/2022	Summary	SBC
Platinum Select PPO 15/40/10% (6BN8)	01/01/2022	Summary	SBC
Platinum Select PPO 5/250/15% (6BL8)	01/01/2022	Summary	SBC
Platinum Select PPO 15/250/10% (6BPF)	01/01/2022	Summary	SBC
Gold Select PPO 25/30% (6BNX)	01/01/2022	Summary	SBC
Gold Select PPO 25/350/20% (6BTD)	01/01/2022	Summary	SBC
Gold Select PPO 30/500/20% (6BP5)	01/01/2022	Summary	SBC
Gold Select PPO 35/500/25% (6BKA)	01/01/2022	Summary	SBC
Gold Select PPO 30/750/20% (6BPX)	01/01/2022	Summary	SBC
Gold Select PPO 35/1000/20% (6BQ5)	01/01/2022	Summary	SBC
Gold Select PPO 5/1500/30% (6BLL)	01/01/2022	Summary	SBC
Silver Select PPO 45/1750/40% (6BQH)	01/01/2022	Summary	SBC
Silver Select PPO 45/1750/40% WH (6BWE) - Whole Health	01/01/2022	Summary	SBC
Silver Select PPO 55/1950/35% (6BQR)	01/01/2022	Summary	SBC
Silver Select PPO 50/2200/40% (6BPP)	01/01/2022	Summary	SBC
Silver Select PPO 50/2250/30% (6BTS)	01/01/2022	Summary	SBC
Silver Select PPO 55/2500/45% (6BKN)	01/01/2022	Summary	SBC
Silver Select PPO 2100/30% w/HSA PrevRx (6BNK/6BTW)	01/01/2022	Summary	SBC
Silver Select PPO 2600/35% w/HSA PrevRx (6BJJ/6BJS)	01/01/2022	Summary	SBC
Bronze Select PPO 4600/50% (6BL0)	01/01/2022	Summary	SBC
Bronze Select PPO 40/6200/40% (6BU8)	01/01/2022	Summary	SBC
Bronze Select PPO 70/6600/35% (6BUV)	01/01/2022	Summary	SBC
Bronze Select PPO 60/6850/40% (6BMJ)	01/01/2022	Summary	SBC
Bronze Select PPO 75/7300/40% (6BK0)	01/01/2022	Summary	SBC
Bronze Select PPO 6000/45% w/HSA PrevRx (6BSB)	01/01/2022	Summary	SBC
Bronze Select PPO 6700/0% w/HSA PrevRx (6BSP)	01/01/2022	Summary	SBC
Bronze Select PPO 7000/0% w/HSA (6BTN)	01/01/2022	Summary	SBC
2021 Medical HMO
CaliforniaCare Full HMO Network
Platinum HMO 20 (5SUJ)	01/01/2021	Summary	SBC
Platinum HMO 25 (5STK)	01/01/2021	Summary	SBC
Gold HMO 30 (5SVG)	01/01/2021	Summary	SBC
Gold HMO 35 (5SWW)	01/01/2021	Summary	SBC
Gold HMO 35/700/20% (5SRZ)	01/01/2021	Summary	SBC
Gold HMO 35/1250/20% (5SSF)	01/01/2021	Summary	SBC
Silver HMO 55 (5ST7)	01/01/2021	Summary	SBC
Silver HMO 55/2250/45% (5SX8)	01/01/2021	Summary	SBC
Select HMO Network
Platinum Select HMO 20 (5SUE)	01/01/2021	Summary	SBC
Platinum Select HMO 25 (5STP)	01/01/2021	Summary	SBC
Gold Select HMO 30 (5SVC)	01/01/2021	Summary	SBC
Gold Select HMO 35 (5SWS)	01/01/2021	Summary	SBC
Gold Select HMO 35/700/20% (5SS3)	01/01/2021	Summary	SBC
Gold Select HMO 35/1250/20% (5SSK)	01/01/2021	Summary	SBC
Silver Select HMO 55 (5STB)	01/01/2021	Summary	SBC
Silver Select HMO 55/2250/45% (5SX4)	01/01/2021	Summary	SBC
Priority Select HMO Network
Platinum Priority Select HMO 20 (5SUN)	01/01/2021	Summary	SBC
Platinum Priority Select HMO 25 (5STT)	01/01/2021	Summary	SBC
Gold Priority Select HMO 30 (5SVL)	01/01/2021	Summary	SBC
Gold Priority Select HMO 35 (5SX0)	01/01/2021	Summary	SBC
Gold Priority Select HMO 35/700/20% (5SS7)	01/01/2021	Summary	SBC
Gold Priority Select HMO 35/1250/20% (5SSB)	01/01/2021	Summary	SBC
Silver Priority Select HMO 55 (5STF)	01/01/2021	Summary	SBC
Silver Priority Select HMO 55/2250/45% (5SXC)	01/01/2021	Summary	SBC
2021 Medical EPO
Prudent Buyer Full PPO Network (BlueCard Network Out-of-State)
Gold EPO 35/500/20% (5SSZ)	01/01/2021	Summary	SBC
Gold EPO 35/1700/20% (5ST3)	01/01/2021	Summary	SBC
2021 Medical PPO
Prudent Buyer Full PPO Network (BlueCard Network Out-of-State)
Platinum PPO 20/10% (5SVU)	01/01/2021	Summary	SBC
Platinum PPO 5/250/15% (5SRH)	01/01/2021	Summary	SBC
Platinum PPO 15/250/10% (5SYC)	01/01/2021	Summary	SBC
Gold PPO 20/30% (5SXU)	01/01/2021	Summary	SBC
Gold PPO 30/500/20% (5SY2)	01/01/2021	Summary	SBC
Gold PPO 35/500/25% (5SQT)	01/01/2021	Summary	SBC
Gold PPO 30/750/20% (5SYU)	01/01/2021	Summary	SBC
Gold PPO 35/1000/20% (5SZ2)	01/01/2021	Summary	SBC
Gold PPO 5/1500/30% (5SRR)	01/01/2021	Summary	SBC
Silver PPO 45/1750/40% (5SZA)	01/01/2021	Summary	SBC
Silver PPO 55/1850/35% (2LHZ)	01/01/2021	Summary	SBC
Silver PPO 50/2200/40% (5SYL)	01/01/2021	Summary	SBC
Silver PPO 55/2500/45% (5SR1)	01/01/2021	Summary	SBC
Silver PPO 2000/30% w/HSA - RxC (5SW5/5SWD)	01/01/2021	Summary	SBC
Silver PPO 2500/35% w/HSA - PrevRx (5T0V/5T0Z)	01/01/2021	Summary	SBC
Bronze PPO 4600/50% (5SR9)	01/01/2021	Summary	SBC
Bronze PPO 40/5600/40% (5SWH)	01/01/2021	Summary	SBC
Bronze PPO 60/6350/40% (5SSR)	01/01/2021	Summary	SBC
Bronze PPO 70/6600/35% (5SXL)	01/01/2021	Summary	SBC
Bronze PPO 75/7300/40% (5T09)	01/01/2021	Summary	SBC
Bronze PPO 5600/45% w/HSA (5STX)	01/01/2021	Summary	SBC
Bronze PPO 6950/0% w/HSA (5SU5)	01/01/2021	Summary	SBC
Prudent Buyer Whole Health Full PPO Network (BlueCard Network Out-of-State)
Platinum PPO 5/250/15% WH (5SZF)	01/01/2021	Summary	SBC
Gold PPO 35/500/25% WH (5SZK)	01/01/2021	Summary	SBC
Gold PPO 35/1000/20% WH (5SZP)	01/01/2021	Summary	SBC
Silver PPO 45/1750/40% WH (5SZT)	01/01/2021	Summary	SBC
Silver PPO 55/2500/45% WH (5SZX)	01/01/2021	Summary	SBC
Bronze PPO 5600/45% w/HSA WH (5T01)	01/01/2021	Summary	SBC
Bronze PPO 6950/0% w/HSA WH (5T05)	01/01/2021	Summary	SBC
Select PPO Network (BlueCard Network Out-of-State)
Platinum Select PPO 15/10% (5SV0)	01/01/2021	Summary	SBC
Platinum Select PPO 20/10% (5SVQ)	01/01/2021	Summary	SBC
Platinum Select PPO 5/250/15% (5SRM)	01/01/2021	Summary	SBC
Platinum Select PPO 15/250/10% (5SYG)	01/01/2021	Summary	SBC
Gold Select PPO 20/30% (5SXY)	01/01/2021	Summary	SBC
Gold Select PPO 25/350/20% (5SUV)	01/01/2021	Summary	SBC
Gold Select PPO 30/500/20% (5SY6)	01/01/2021	Summary	SBC
Gold Select PPO 35/500/25% (5SQX)	01/01/2021	Summary	SBC
Gold Select PPO 30/750/20% (5SYY)	01/01/2021	Summary	SBC
Gold Select PPO 35/1000/20% (5SZ6)	01/01/2021	Summary	SBC
Gold Select PPO 5/1500/30% (5SRV)	01/01/2021	Summary	SBC
Silver Select PPO 45/1750/40% (5SZE)	01/01/2021	Summary	SBC
Silver Select PPO 55/1850/35% (2LHV)	01/01/2021	Summary	SBC
Silver Select PPO 55/2500/45% (5SR5)	01/01/2021	Summary	SBC
Silver Select PPO 50/2200/40% (5SYQ)	01/01/2021	Summary	SBC
Silver Select PPO 50/2250/30% (5SV8)	01/01/2021	Summary	SBC
Silver Select PPO 2000/30% w/HSA - RxC (5SW1/5SW9)	01/01/2021	Summary	SBC
Silver Select PPO 2500/35% w/HSA - PrevRx (5T13/5T17)	01/01/2021	Summary	SBC
Bronze Select PPO 4600/50% (5SRD)	01/01/2021	Summary	SBC
Bronze Select PPO 40/5600/40% (5SWM)	01/01/2021	Summary	SBC
Bronze Select PPO 60/6350/40% (5SSV)	01/01/2021	Summary	SBC
Bronze Select PPO 70/6600/35% (5SXQ)	01/01/2021	Summary	SBC
Bronze Select PPO 75/7300/40% (5T0D)	01/01/2021	Summary	SBC
Bronze Select PPO 5600/45% w/HSA (5SU1)	01/01/2021	Summary	SBC
Bronze Select PPO 6950/0% w/HSA (5SU9)	01/01/2021	Summary	SBC
Bronze Select PPO 7000/0% w/HSA (5SV4)	01/01/2021	Summary	SBC

Form Name	Effective Date	Download Form
General Information
2020 Small Group Broker Guide	01/01/2020	Download
2021 Portfolio Highlights	01/01/2021	Download
Small Group Eligibility Guidelines	01/01/2022	Download
Small Group Product Guide 1.21	01/01/2021	Download
Underwriting Guidelines 1.23	01/01/2023	Download
Top 10 Reasons To Sell Anthem	01/01/2020	Download
Employer's Guide to the Premium Only Plan	01/01/2020	Download
FAQ on American Rescue Plan COBRA and State Continuation Subsidies Brochure	04/01/2021	Download
Helpful Information & Resources Flyer	01/01/2022	Download
Member Website Overview	01/01/2020	Download
Mobile App - Say hi to Sydney	01/01/2020	Download
Mobile App - Pharmacy Tools	01/01/2020	Download
Online Provider Search Instructions	01/01/2020	Download
Overview of ACA Taxes and Fees	01/01/2020	Download
PayForward Flyer	01/01/2020	Download
Resource Advisor Flyer	01/01/2020	Download
Special Offers and Discounts Flyer	01/01/2020	Download
Vivity Broker Brochure	11/01/2022	Download
Vivity Member Brochure	01/01/2021	Download
Vivity Member Experience Concierge Assistance Flyer	01/01/2021	Download
Vivity Away from Home Guest Membership	01/01/2022	Download
Medical
Small Group Medical Product Overview 1.22	01/01/2022	Download
Small Group Medical Product Guide 1.22	01/01/2022	Download
2022 Medical Renewal Plan Mapping Grid	01/01/2022	Download
HMO Network Comparison Guide 1.23	01/01/2023	Download
HSA Flyer	01/01/2022	Download
Blue Card Program Flyer	01/01/2020	Download
Infertility Rider Rating Flyer	01/01/2020	Download
LiveHealth Online Employee Brochure	01/01/2020	Download
LiveHealth Online Psychiatry Flyer	01/01/2020	Download
LiveHealth Online Psychology Flyer	01/01/2020	Download
Mail Order Prescriptions Flyer	01/01/2020	Download
Prescription Drug 4-Tier Small Group Formulary	01/01/2020	Download
Prescription Drug 4-Tier w/ Split Tier 1 Small Group Formulary	01/01/2020	Download
Preventive Care Benefits	01/01/2020	Download
SBC Flyer	01/01/2020	Download
Silver HSA Brochure	01/01/2020	Download
Urgent Care vs Emergency Room Flyer	01/01/2020	Download
Wellness Resources Brochure	01/01/2020	Download
Dental
Dental Net DHMO Plan Comparison (no longer marketed 2000-Series compared to new 3000-Series)	01/01/2020	Download
Dental Net DHMO Product Brochure	01/01/2020	Download
Dental Metallic PPO and DHMO Product Grid	01/01/2022	Download
Online Dental HMO Provider Search Instructions	01/01/2021	Download
Online Dental PPO Complete Provider Search Instructions	01/01/2021	Download
Online Dental HMO & PPO Complete Provider Search Instructions	01/01/2021	Download
Dental PPO Annual Max Carry-Over Flyer	01/01/2020	Download
Dental PPO Unlimited & Traditional Annual Maximums Flyer	01/01/2020	Download
International Dental Emergency Care Flyer	01/01/2020	Download
Dental Provider Nomination Form	01/01/2020	Download
Vision
Blue View Vision Product Grid	01/01/2022	Download
Blue View Vision Plan Enhancements 2020	01/01/2020	Download
2020 Vision Contract Code List	01/01/2020	Download
Online Vision Provider Search Instructions	01/01/2021	Download
Importance of Vision Exams Flyer	01/01/2020	Download
Life & Disability
Life & Disability Product Grid	01/01/2022	Download
Travel Assistance Brochure	01/01/2020	Download

Form Name	Effective Date	Download Form
Rate Guide - All Rating Areas [effective 1/1/2023]	01/01/2023	Download

Anthem Blue Cross

At Anthem Blue Cross we understand our health connects us to each other. What we all do impacts those around us. So Anthem is dedicated to delivering better care to our members, providing greater value to our customers and helping improve the health of our communities.

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