| 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 |
