Form Name | Effective Date | Download Form |
---|---|---|
New Group Submissions |
||
New Business Submission Checklist - Small Group 1.23 |
01/01/2023 | Download |
Employer Application - Small Group 1.23 |
01/01/2023 | Download |
New Business Submission Checklist - Small Group 1.22 |
01/01/2022 | Download |
Employer Application - Small Group 1.22 |
01/01/2022 | Download |
Sole Proprietor, Partner or Corporate Officer Eligibility Statement |
12/01/2022 | Download |
New Business Submission Checklist - Large Group 1.23 |
01/01/2023 | Download |
Employer Application - Large Group 1.23 |
01/01/2023 | Download |
New Business Submission Checklist - Large Group 1.22 |
01/01/2022 | Download |
Employer Application - Large Group 1.22 |
01/01/2022 | Download |
Administration |
||
Employer Administrative Guide |
01/01/2022 | Download |
Termination Form |
12/01/2022 | Download |
Form Name | Effective Date | Download Form |
---|---|---|
Enrollment and Change Forms |
||
Employee Enrollment and Change Form - Small Group 1.23 |
01/01/2023 | Download |
Employee Enrollment and Change Form - Large Group 1.23 |
01/01/2023 | Download |
Employee Enrollment and Change Form - Small Group 1.22 |
01/01/2022 | Download |
Employee Enrollment and Change Form - Large Group 1.22 |
01/01/2022 | Download |
Declination of Coverage Form |
01/01/2022 | Download |
Continuity of Care Services Request Form |
01/01/2022 | Download |
Disable Dependent Certification Form |
01/01/2022 | Download |
Claim Forms |
||
Authorization for the Use or Disclosure of Health Information |
01/01/2022 | Download |
Member Claim Form |
01/01/2022 | Download |
Mail Order Rx Delivery Form |
01/01/2022 | Download |
Form Name | Effective Date | Download Form | |
---|---|---|---|
2023 Small Group Standard Medical HMO |
|||
Platinum MS68 HMO |
01/01/2023 | Summary | SBC |
Platinum MS80 HMO |
01/01/2023 | Summary | SBC |
Gold MS62 HMO |
01/01/2023 | Summary | SBC |
Gold MS77 HMO |
01/01/2023 | Summary | SBC |
Gold MS83 HMO |
01/01/2023 | Summary | SBC |
Gold SD02 HDHP HMO |
01/01/2023 | Summary | SBC |
Silver MS84 HMO |
01/01/2023 | Summary | SBC |
Silver SD01 HDHP HMO |
01/01/2023 | Summary | SBC |
Bronze MS86 HMO |
01/01/2023 | Summary | SBC |
Bronze SD48 HDHP HMO |
01/01/2023 | Summary | SBC |
2023 Small Group Plus Medical HMO (Contact your RBG representative for a Plus HMO plan quote) |
|||
Platinum MP68 Plus HMO |
01/01/2023 | Summary | SBC |
Platinum MP80 Plus HMO |
01/01/2023 | Summary | SBC |
Gold MP62 Plus HMO |
01/01/2023 | Summary | SBC |
Gold MP77 Plus HMO |
01/01/2023 | Summary | SBC |
Gold MP83 Plus HMO |
01/01/2023 | Summary | SBC |
Gold SP02 HDHP Plus HMO |
01/01/2023 | Summary | SBC |
Silver MP84 Plus HMO |
01/01/2023 | Summary | SBC |
Silver SP01 HDHP Plus HMO |
01/01/2023 | Summary | SBC |
Bronze MP86 Plus HMO |
01/01/2023 | Summary | SBC |
Bronze SP48 HDHP Plus HMO |
01/01/2023 | Summary | SBC |
2023 Large Group Medical HMO |
|||
Summit ML61 HMO |
01/01/2023 | Summary | SBC |
Summit ML62 HMO |
01/01/2023 | Summary | SBC |
Summit ML63 HMO |
01/01/2023 | Summary | SBC |
Summit ML64 HMO |
01/01/2023 | Summary | SBC |
Summit ML65 HMO |
01/01/2023 | Summary | SBC |
Summit ML66 HMO |
01/01/2023 | Summary | SBC |
Summit ML67 HMO |
01/01/2023 | Summary | SBC |
Peak ML68 HMO |
01/01/2023 | Summary | SBC |
Peak ML69 HMO |
01/01/2023 | Summary | SBC |
Peak ML70 HMO |
01/01/2023 | Summary | SBC |
Peak ML71 HMO |
01/01/2023 | Summary | SBC |
Peak ML72 HMO |
01/01/2023 | Summary | SBC |
Peak ML73 HMO |
01/01/2023 | Summary | SBC |
Peak ML77 HMO |
01/01/2023 | Summary | SBC |
Ridge ML74 HMO |
01/01/2023 | Summary | SBC |
Ridge ML75 HMO |
01/01/2023 | Summary | SBC |
Ridge ML76 HMO |
01/01/2023 | Summary | SBC |
Vista HD20 HDHP HMO |
01/01/2023 | Summary | SBC |
Vista HD21 HDHP HMO |
01/01/2023 | Summary | SBC |
Vista HD22 HDHP HMO |
01/01/2023 | Summary | SBC |
Vista HD23 HDHP HMO |
01/01/2023 | Summary | SBC |
Vista HD24 HDHP HMO |
01/01/2023 | Summary | SBC |
Vista HD25 HDHP HMO |
01/01/2023 | Summary | SBC |
Vista HD26 HDHP HMO |
01/01/2023 | Summary | SBC |
2022 Small Group Standard Medical HMO |
|||
Platinum MS58 HMO |
01/01/2022 | Summary | SBC |
Platinum MS70 HMO |
01/01/2022 | Summary | SBC |
Gold MS52 HMO |
01/01/2022 | Summary | SBC |
Gold MS67 HMO |
01/01/2022 | Summary | SBC |
Gold MS73 HMO |
01/01/2022 | Summary | SBC |
Silver MS74 HMO |
01/01/2022 | Summary | SBC |
Silver SD47 HDHP HMO |
01/01/2022 | Summary | SBC |
Bronze MS76 HMO |
01/01/2022 | Summary | SBC |
Bronze SD38 HDHP HMO |
01/01/2022 | Summary | SBC |
2022 Small Group Plus Medical HMO (Contact your RBG representative for a Plus HMO plan quote) |
|||
Platinum MP58 Plus HMO |
01/01/2022 | Summary | SBC |
Platinum MP70 Plus HMO |
01/01/2022 | Summary | SBC |
Gold MP52 Plus HMO |
01/01/2022 | Summary | SBC |
Gold MP67 Plus HMO |
01/01/2022 | Summary | SBC |
Gold MP73 Plus HMO |
01/01/2022 | Summary | SBC |
Silver MP74 Plus HMO |
01/01/2022 | Summary | SBC |
Silver SP47 Plus HDHP HMO |
01/01/2022 | Summary | SBC |
Bronze MP76 Plus HMO |
01/01/2022 | Summary | SBC |
Bronze SP38 Plus HDHP HMO |
01/01/2022 | Summary | SBC |
2022 Large Group Medical HMO |
|||
Summit ML26 HMO |
01/01/2022 | Summary | SBC |
Summit ML27 HMO |
01/01/2022 | Summary | SBC |
Summit ML28 HMO |
01/01/2022 | Summary | SBC |
Summit ML29 HMO |
01/01/2022 | Summary | SBC |
Summit ML50 HMO |
01/01/2022 | Summary | SBC |
Summit ML51 HMO |
01/01/2022 | Summary | SBC |
Summit ML54 HMO |
01/01/2022 | Summary | SBC |
Peak ML20 HMO |
01/01/2022 | Summary | SBC |
Peak ML21 HMO |
01/01/2022 | Summary | SBC |
Peak ML22 HMO |
01/01/2022 | Summary | SBC |
Peak ML24 HMO |
01/01/2022 | Summary | SBC |
Peak ML25 HMO |
01/01/2022 | Summary | SBC |
Peak ML59 HMO |
01/01/2022 | Summary | SBC |
Peak ML60 HMO |
01/01/2022 | Summary | SBC |
Ridge ML56 HMO |
01/01/2022 | Summary | SBC |
Ridge ML57 HMO |
01/01/2022 | Summary | SBC |
Ridge ML58 HMO |
01/01/2022 | Summary | SBC |
Vista HD08 HDHP HMO |
01/01/2022 | Summary | SBC |
Vista HD09 HDHP HMO |
01/01/2022 | Summary | SBC |
Vista HD10 HDHP HMO |
01/01/2022 | Summary | SBC |
Vista HD15 HDHP HMO |
01/01/2022 | Summary | SBC |
Vista HD17 HDHP HMO |
01/01/2022 | Summary | SBC |
Vista HD18 HDHP HMO |
01/01/2022 | Summary | SBC |
Vista HD19 HDHP HMO |
01/01/2022 | Summary | SBC |
Form Name | Effective Date | Download Form |
---|---|---|
General Information |
||
Small Group Medical Plan Comparisons 1.23 |
01/01/2023 | Download |
Small Group Underwriting Guidelines 1.23 |
01/01/2023 | Download |
Small Group Medical Plan Comparisons 1.22 |
01/01/2022 | Download |
Small Group Underwriting Guidelines 1.22 |
01/01/2022 | Download |
Large Group Medical Plan Comparisons 1.23 |
01/01/2023 | Download |
Large Group Medical Plan Comparisons 1.22 |
01/01/2022 | Download |
Optional Benefits Plan Comparisons 1.23 |
01/01/2023 | Download |
Optional Benefits Plan Comparisons 1.22 |
01/01/2022 | Download |
Employer Premium Payment Options Flyer |
01/01/2022 | Download |
Member Booklet - Great Coverage Starts Here |
01/01/2022 | Download |
Pharmacy Benefits - Managing Your Prescriptions |
01/01/2022 | Download |
Form Name | Effective Date | Download Form |
---|---|---|
SG Rate Guide - All Rating Areas [effective 1/1/2023] |
01/01/2023 | Download |
SG Optional Benefits Rate Flyer [effective 1/1/2023] |
01/01/2023 | Download |
SG Rate Guide - All Rating Areas [effective 10/1/2022] |
10/01/2022 | Download |
SG Optional Benefits Rate Flyer [effective 1/1/2022] |
01/01/2022 | Download |