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.

Provider Finder 

Form Name Effective Date Download Form
New Group Submission
Employer Application - All Lines 1.21
01/01/2021 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 1.21
01/01/2021 Download
Proprietor/Partner/Corporate Officer Eligibility Statement
01/01/2020 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
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
01/01/2020 Download
Employer Contact Sheet - Where to Go!
01/01/2020 Download
Form Name Effective Date Download Form
Enrollment and Change Forms
Employee Application 1.21
01/01/2021 Download
Employee Application 1.22
01/01/2022 Download
Employee Waiver Form 1.21
01/01/2021 Download
Employee Waiver Form 1.22
01/01/2022 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
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
2020 Medical HMO
CaliforniaCare Full HMO Network
Platinum HMO 20 (4HYZ)
01/01/2020 Summary SBC
Platinum HMO 25 (4HTT)
01/01/2020 Summary SBC
Gold HMO 30 (4HV5)
01/01/2020 Summary SBC
Gold HMO 35 (4HUV)
01/01/2020 Summary SBC
Gold HMO 35/500/20% (5B0L) [new effective 7/1/2020]
07/01/2020 Summary SBC
Gold HMO 35/1250/20% (5B0Q) [new effective 7/1/2020]
07/01/2020 Summary SBC
Silver HMO 55 (4HTA)
01/01/2020 Summary SBC
Silver HMO 55/2250/45% (4HYF)
01/01/2020 Summary SBC
Select HMO Network
Platinum Select HMO 20 (4HYV)
01/01/2020 Summary SBC
Platinum Select HMO 25 (4HTX)
01/01/2020 Summary SBC
Gold Select HMO 30 (4HV1)
01/01/2020 Summary SBC
Gold Select HMO 35 (4HUP)
01/01/2020 Summary SBC
Gold Select HMO 35/500/20% (5B1A) [new effective 7/1/2020]
07/01/2020 Summary SBC
Gold Select HMO 35/1250/20% (5B12) [new effective 7/1/2020]
07/01/2020 Summary SBC
Silver Select HMO 55 (4HTE)
01/01/2020 Summary SBC
Silver Select HMO 55/2250/45% (4HYC)
01/01/2020 Summary SBC
Priority Select HMO Network
Platinum Priority Select HMO 20 (4HZ2)
01/01/2020 Summary SBC
Platinum Priority Select HMO 25 (4HU1)
01/01/2020 Summary SBC
Gold Priority Select HMO 30 (4HV8)
01/01/2020 Summary SBC
Gold Priority Select HMO 35 (4HUW)
01/01/2020 Summary SBC
Gold Priority Select HMO 35/500/20% (5B1E) [new effective 7/1/2020]
07/01/2020 Summary SBC
Gold Priority Select HMO 35/1250/20% (5B16) [new effective 7/1/2020]
07/01/2020 Summary SBC
Silver Priority Select HMO 55 (4HTF)
01/01/2020 Summary SBC
Silver Priority Select HMO 55/2250/45% (4HYK)
01/01/2020 Summary SBC
2020 Medical EPO
Prudent Buyer Full PPO Network (BlueCard Network Out-of-State)
Gold EPO 35/500/20% (4HT2)
01/01/2020 Summary SBC
Gold EPO 35/1700/20% (4HT6)
01/01/2020 Summary SBC
2020 Medical PPO
Prudent Buyer Full PPO Network (BlueCard Network Out-of-State)
Platinum PPO 20/10% (4HVH)
01/01/2020 Summary SBC
Platinum PPO 5/250/20% (5B0C) [new effective 7/1/2020]
07/01/2020 Summary SBC
Platinum PPO 15/250/10% (4HWQ)
01/01/2020 Summary SBC
Gold PPO 20/30% (4HW6)
01/01/2020 Summary SBC
Gold PPO 30/500/20% (4HWE)
01/01/2020 Summary SBC
Gold PPO 35/500/25% (4HZS)
01/01/2020 Summary SBC
Gold PPO 30/750/20% (4HX6)
01/01/2020 Summary SBC
Gold PPO 35/1000/20% (4HXE)
01/01/2020 Summary SBC
Gold PPO 5/1400/30% (5B0G) [new effective 7/1/2020]
07/01/2020 Summary SBC
Silver PPO 45/1750/40% (4HXN)
01/01/2020 Summary SBC
Silver PPO 55/1850/35% (4HY0)
01/01/2020 Summary SBC
Silver PPO 50/2000/40% (4HWY)
01/01/2020 Summary SBC
Silver PPO 55/2500/45% (4J00)
01/01/2020 Summary SBC
Silver PPO 2000/30% w/HSA - RxC (4HVU/4HW2)
01/01/2020 Summary SBC
Bronze PPO 3950/50% (4J08)
01/01/2020 Summary SBC
Bronze PPO 40/5600/40% (4HUE) [plan discontinued 4/30/2020]
01/01/2020 Summary SBC
Bronze PPO 40/5600/40% (5KY4) [updated benefits for groups effective 5/1/2020 and later]
05/01/2020 Summary SBC
Bronze PPO 70/6300/35% (4HY6) [plan discontinued 4/30/2020]
01/01/2020 Summary SBC
Bronze PPO 70/6300/35% (5KYL) [updated benefits for groups effective 5/1/2020 and later]
05/01/2020 Summary SBC
Bronze PPO 60/6350/40% (4HU5) [plan discontinued 4/30/2020]
01/01/2020 Summary SBC
Bronze PPO 60/6350/40% (5KYC) [updated benefits for groups effective 5/1/2020 and later]
05/01/2020 Summary SBC
Bronze PPO 5000/45% w/HSA (52SH)
01/01/2020 Summary SBC
Bronze PPO 6600/0% w/HSA (52SM)
01/01/2020 Summary SBC
Select PPO Network (BlueCard Network Out-of-State)
Platinum Select PPO 15/10% (4HZE)
01/01/2020 Summary SBC
Platinum Select PPO 20/10% (4HVD)
01/01/2020 Summary SBC
Platinum Select PPO 5/250/20% (5B1N) [new effective 7/1/2020]
07/01/2020 Summary SBC
Platinum Select PPO 15/250/10% (4HWU)
01/01/2020 Summary SBC
Gold Select PPO 20/30% (4HWA)
01/01/2020 Summary SBC
Gold Select PPO 25/250/20% (4HZ9)
01/01/2020 Summary SBC
Gold Select PPO 30/500/20% (4HWJ)
01/01/2020 Summary SBC
Gold Select PPO 35/500/25% (4HZW)
01/01/2020 Summary SBC
Gold Select PPO 30/750/20% (4HXA)
01/01/2020 Summary SBC
Gold Select PPO 35/1000/20% (4HXJ)
01/01/2020 Summary SBC
Gold Select PPO 5/1400/30% (5B1J) [new effective 7/1/2020]
07/01/2020 Summary SBC
Silver Select PPO 45/1750/40% (4HXS)
01/01/2020 Summary SBC
Silver Select PPO 55/1850/35% (4HXW)
01/01/2020 Summary SBC
Silver Select PPO 50/2000/40% (4HX2)
01/01/2020 Summary SBC
Silver Select PPO 50/2250/20% (4HZP)
01/01/2020 Summary SBC
Silver Select PPO 55/2500/45% (4J04)
01/01/2020 Summary SBC
Silver Select PPO 2000/30% w/HSA - RxC (4HVQ/4HVY)
01/01/2020 Summary SBC
Bronze Select PPO 3950/50% (4J0C)
01/01/2020 Summary SBC
Bronze Select PPO 40/5600/40% (4HUJ) [plan discontinued 4/30/2020]
01/01/2020 Summary SBC
Bronze Select PPO 40/5600/40% (5KY8) [updated benefits for groups effective 5/1/2020 and later]
05/01/2020 Summary SBC
Bronze Select PPO 70/6300/35% (4HY7) [plan discontinued 4/30/2020]
01/01/2020 Summary SBC
Bronze Select PPO 70/6300/35% (5KYQ) [updated benefits for groups effective 5/1/2020 and later]
05/01/2020 Summary SBC
Bronze Select PPO 60/6350/40% (4HU9) [plan discontinued 4/30/2020]
01/01/2020 Summary SBC
Bronze Select PPO 60/6350/40% (5KYG) [updated benefits for groups effective 5/1/2020 and later]
05/01/2020 Summary SBC
Bronze Select PPO 5000/45% w/HSA (52H9)
01/01/2020 Summary SBC
Bronze Select PPO 6600/0% w/HSA (52HD)
01/01/2020 Summary SBC
Bronze Select PPO 6900/0% w/HSA (4HZJ)
01/01/2020 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 Product Guide 1.21
01/01/2021 Download
Underwriting Guidelines 1.21
01/01/2021 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
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
01/01/2021 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 1.21
01/01/2021 Download
Small Group Medical Product Overview 1.22
01/01/2022 Download
Small Group Medical Product Guide 1.21
01/01/2021 Download
Small Group Medical Product Guide 1.22
01/01/2022 Download
Medical Contract Code List
05/01/2020 Download
2021 Medical Renewal Plan Mapping Grid
01/01/2021 Download
HMO Network Comparison Guide 3.21
03/01/2021 Download
HMO Network Comparison Guide 1.22
01/01/2022 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
01/01/2021 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
01/01/2021 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
01/01/2021 Download
Travel Assistance Brochure
01/01/2020 Download
Form Name Effective Date Download Form
Rate Guide - All Rating Areas [effective 1/1/2022]
01/01/2022 Download