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
Anthem Small Group Submission Checklist
01/01/2018 Download
Employer Application
09/01/2018 Download
Electronic Debit Payment/Recurring Payment Option
01/01/2018 Download
Proprietor/Partner/Corporate Officer Eligibility Statement
01/01/2017 Download
Conditions of Enrollment Start Up Companies PEO Spin Offs
01/01/2018 Download
Group Size Attestation Form
01/01/2018 Download
Instructions - Group Size Attestation Form
01/01/2018 Download
In Force Group Forms
Anniversary Month Change Form
01/01/2018 Download
Employer Information Change Form
01/01/2018 Download
Group Renewal Plan Change Request Form
01/01/2018 Download
Specialty Benefit Modification Form (for existing groups adding or changing specialty coverage)
06/01/2018 Download
Administration
Employer Group Administrator Manual
01/01/2018 Download
Employer Contact Sheet - Where to Go!
01/01/2018 Download
Form Name Effective Date Download Form
Enrollment and Change Forms
Employee Application
01/01/2018 Download
Employee Change Form
01/01/2018 Download
Employee Waiver Form
01/01/2018 Download
Custodial Verification Form
01/01/2018 Download
Handicapped Dependent Certification Form
01/01/2018 Download
Transition of Care Policy
01/01/2018 Download
Transition of Care Form
01/01/2018 Download
Transition of Care Form - Spanish
01/01/2018 Download
Claim Forms
Member Authorization (HIPAA) Form
01/01/2018 Download
Member Authorization (HIPAA) Form - Spanish
01/01/2018 Download
Medical Claim Form
01/01/2018 Download
Pharmacy Claim Form
01/01/2018 Download
Pharmacy Prior Authorization Form
01/01/2018 Download
Form Name Effective Date Download Form
2018 Medical HMO
CaliforniaCare Full HMO Network
Platinum HMO 10/10%/2000 - 300D
01/01/2018 Summary SBC
Gold HMO 25/20%/5500 - 304R
01/01/2018 Summary SBC
Gold HMO 40/20%/4500 - 301V
01/01/2018 Summary SBC
Gold HMO 500/20%/5000 - 2ZYU
01/01/2018 Summary SBC
Gold HMO 1000/30%/4000 - 305F
01/01/2018 Summary SBC
Silver HMO 1500/35%/7150 - 304Z
01/01/2018 Summary SBC
Silver HMO 2000/40%/7350 - 2ZZ2
01/01/2018 Summary SBC
Select HMO Network
Platinum Select HMO 10/10%/2000 - 3009
01/01/2018 Summary SBC
Gold Select HMO 25/20%/5500 - 304M
01/01/2018 Summary SBC
Gold Select HMO 40/20%/4500 - 301R
01/01/2018 Summary SBC
Gold Select HMO 500/20%/5000 - 2ZYQ
01/01/2018 Summary SBC
Gold Select HMO 1000/30%/4000 - 305K
01/01/2018 Summary SBC
Silver Select HMO 1500/35%/7150 - 304V
01/01/2018 Summary SBC
Silver Select HMO 2000/40%/7350 - 2ZYY
01/01/2018 Summary SBC
2018 Medical PPO
Prudent Buyer Full PPO Network
Platinum PPO 20/10%/3000 - 3057
01/01/2018 Summary SBC
Platinum PPO 200/10%/3000 - 3037
01/01/2018 Summary SBC
Gold PPO 20/30%/6500 - 302G
01/01/2018 Summary SBC
Gold PPO 500/20%/6500 - 302Q
01/01/2018 Summary SBC
Gold PPO 750/20%/6500 - 303P
01/01/2018 Summary SBC
Gold PPO 1000/20%/6000 - 303X
01/01/2018 Summary SBC
Gold PPO 2000/20%/4000 - 3024
01/01/2018 Summary SBC
Silver PPO 1250/40%/7350 - 3045
01/01/2018 Summary SBC
Silver PPO 1750/35%/7350 - 304H
01/01/2018 Summary SBC
Silver PPO 2000/40%/7350 - 303F
01/01/2018 Summary SBC
Silver PPO 2000/20%/6000 wHSA - RxC - 99A2 Employee Only Coverage
01/01/2018 Summary SBC
Silver PPO 2000/20%/6000 wHSA - RxC - 99AF Employee & Dependent Coverage
01/01/2018 Summary SBC
Bronze PPO 4000/40%/7350 - 305X
07/01/2018 Summary SBC
Bronze PPO 5000/30%/7350 - 301D
01/01/2018 Summary SBC
Bronze PPO 6000/35%/7350 - 3028
01/01/2018 Summary SBC
Bronze PPO 4500/35%/6550 wHSA - 3065
01/01/2018 Summary SBC
Bronze PPO 5000/35%/6550 wHSA - 2ZZN
01/01/2018 Summary SBC
Bronze PPO 6500/0%/6500 wHSA - 2ZZW
01/01/2018 Summary SBC
Select PPO Network
Platinum Select PPO 15/10%/3350 - 300Z
01/01/2018 Summary SBC
Platinum Select PPO 20/10%/3000 - 3053
01/01/2018 Summary SBC
Platinum Select PPO 200/10%/3000 - 303B
01/01/2018 Summary SBC
Gold Select PPO 20/30%/6500 - 302L
01/01/2018 Summary SBC
Gold Select PPO 25/20%/6000 - 300R
01/01/2018 Summary SBC
Gold Select PPO 500/20%/6500 - 302U
01/01/2018 Summary SBC
Gold Select PPO 750/20%/6500 - 303T
01/01/2018 Summary SBC
Gold Select PPO 1000/20%/6000 - 3041
01/01/2018 Summary SBC
Gold Select PPO 2000/20%/4000 - 301Z
01/01/2018 Summary SBC
Silver Select PPO 1250/40%/7350 - 3049
01/01/2018 Summary SBC
Silver Select PPO 1750/35%/7350 - 304D
01/01/2018 Summary SBC
Silver Select PPO 2000/20%/7000 - 3018
01/01/2018 Summary SBC
Silver Select PPO 2000/40%/7350 - 303K
01/01/2018 Summary SBC
Silver Select PPO 2000/20%/6000 wHSA - RxC - 999Y Employee Only Coverage
01/01/2018 Summary SBC
Silver Select PPO 2000/20%/6000 wHSA - RxC - 99AB Employee & Dependent Coverage
01/01/2018 Summary SBC
Bronze Select PPO 4000/40%/7350 - 3061
07/01/2018 Summary SBC
Bronze Select PPO 5000/30%/7350 - 301H
01/01/2018 Summary SBC
Bronze Select PPO 6000/35%/7350 - 302C
01/01/2018 Summary SBC
Bronze Select PPO 4500/35%/6550 w/HSA - 3069
01/01/2018 Summary SBC
Bronze Select PPO 4800/40%/6550 wHSA - 3013
01/01/2018 Summary SBC
Bronze Select PPO 5000/35%/6550 wHSA - 2ZZS
01/01/2018 Summary SBC
Bronze Select PPO 6500/0%/6500 wHSA - 3000
01/01/2018 Summary SBC
2017 Medical HMO
CaliforniaCare Full HMO Network
Platinum HMO 10/10%/2700 - 2EZG
01/01/2017 Summary SBC
Gold HMO 25/20%/6600 - 2EZU
01/01/2017 Summary SBC
Gold HMO 40/20%/6500 - 2EWB
01/01/2017 Summary SBC
Gold HMO 500/20%/6500 - 1ZPS
01/01/2017 Summary SBC
Silver HMO 1500/35%/7150 - 2F9C
01/01/2017 Summary SBC
Silver HMO 1750/40%/7150 - 2F9L
01/01/2017 Summary SBC
Silver HMO 2000/40%/7150 - 1ZQ3
01/01/2017 Summary SBC
Select HMO Network
Platinum Select HMO 10/10%/2700 - 1ZS0
01/01/2017 Summary SBC
Gold Select HMO 25/20%/6600 - 2EZQ
01/01/2017 Summary SBC
Gold Select HMO 40/20%/6500 - 2EW1
01/01/2017 Summary SBC
Gold Select HMO 500/20%/6500 - 1ZPN
01/01/2017 Summary SBC
Silver Select HMO 1500/35%/7150 - 2F98
01/01/2017 Summary SBC
Silver Select HMO 1750/40%/7150 - 2F9G
01/01/2017 Summary SBC
Silver Select HMO 2000/40%/7150 1ZQ0
01/01/2017 Summary SBC
2017 Medical PPO
Prudent Buyer Full PPO Network
Platinum PPO 20/10%/4000 - 2F9Q
01/01/2017 Summary SBC
Platinum PPO 200/10%/4000 - 2EXY
01/01/2017 Summary SBC
Gold PPO 20/30%/6500 - 2EXB
01/01/2017 Summary SBC
Gold PPO 500/20%/6500 - 2EXF
01/01/2017 Summary SBC
Gold PPO 700/20%/6600 - 2EXQ
01/01/2017 Summary SBC
Gold PPO 1000/20%/6000 - 2EXU
01/01/2017 Summary SBC
Gold PPO 2000/20%/4000 2EWH
01/01/2017 Summary SBC
Silver PPO 1250/40%/7150 - 2EY6
01/01/2017 Summary SBC
Silver PPO 1750/35%/7150 2EYE
01/01/2017 Summary SBC
Silver PPO 2000/35%/7150 - 2EY2
01/01/2017 Summary SBC
Silver PPO 2000_20%_5400 wHSA RxC CDHP - 9996 Employee Only Coverage
01/01/2017 Summary SBC
Silver PPO 2000/20%/5400 wHSA RxC CDHP - 999F Employee & Dependent Coverage
01/01/2017 Summary SBC
Bronze PPO 5000/30%/7150 - 2EVN
01/01/2017 Summary SBC
Bronze PPO 6000/35%/7150 - 2EWP
01/01/2017 Summary SBC
Bronze PPO 5000/35%/6550 wHSA - 1ZQQ
01/01/2017 Summary SBC
Bronze PPO 6500/0%/6500 wHSA - 1ZR2
01/01/2017 Summary SBC
Select PPO Network
Platinum Select PPO 15/10%/4000 - 1ZSK
01/01/2017 Summary SBC
Platinum Select PPO 20/10%/4000 - 2F90
01/01/2017 Summary SBC
Platinum Select PPO 200/10%/4000 - 2EZ4
01/01/2017 Summary SBC
Gold Select PPO 20/30%/6500 - 2EYS
01/01/2017 Summary SBC
Gold Select PPO 30/20%/6750 - 1ZSB
01/01/2017 Summary SBC
Gold Select PPO 500/20%/6500 - 2EYW
01/01/2017 Summary SBC
Gold Select PPO 700/20%/6600 - 2EZ0
01/01/2017 Summary SBC
Gold Select PPO 1000/20%/6000 - 2EYN
01/01/2017 Summary SBC
Gold Select PPO 2000/20%/4000 - 2EWD
01/01/2017 Summary SBC
Silver Select PPO 1250/40%/7150 2EZ8
01/01/2017 Summary SBC
Silver Select PPO 1750/35%/7150 2EYA
01/01/2017 Summary SBC
Silver Select PPO 2000/20%/6800 - 1ZSU
01/01/2017 Summary SBC
Silver Select PPO 2000/35%/7150 - 2EZC
01/01/2017 Summary SBC
Silver Select PPO 2000/20%/5400 wHSA RxC CDHP - 999B Employee Only Coverage
01/01/2017 Summary SBC
Silver Select PPO 2000/20%/5400 wHSA RxC CDHP - 999K Employee & Dependent Coverage
01/01/2017 Summary SBC
Bronze Select PPO 5000/30%/7150 - 2EVS
01/01/2017 Summary SBC
Bronze Select PPO 6000/35%/7150 2EWQ
01/01/2017 Summary SBC
Bronze Select PPO 4800/40%/6550 wHSA CDHP - 1ZSP
01/01/2017 Summary SBC
Bronze Select PPO 5000/35%/6550 wHSA CDHP - 1ZQU
01/01/2017 Summary SBC
Bronze Select PPO 6500/0%/6500 wHSA CDHP - 1ZR5
01/01/2017 Summary SBC
2018 Dental Plans
DHMO Plans
DentalNet 2000A
01/01/2018 Summary
DentalNet 2000B
01/01/2018 Summary
DentalNet 2000C
01/01/2018 Summary
Metallic Dental Complete PPO Plans
Platinum Dental PPO Plans
Platinum PPO 100/90/60 Active 50/2000 90th E&P Basic (2RJP)
01/01/2018 Summary
Platinum PPO 100/90/60 Active 50/2000 90th E&P Basic Ortho (2RJN)
01/01/2018 Summary
Platinum PPO Voluntary 100/90/60 Active 50/2000 90th E&P Basic (2RJR)
01/01/2018 Summary
Platinum PPO Voluntary 100/90/60 Active 50/2000 90th E&P Basic Ortho (2RJQ)
01/01/2018 Summary
Gold Dental PPO Plans
32JL
01/01/2018
Gold PPO 100/90/60 Active 50/1500 90th E&P Basic Ortho (32JM)
01/01/2018 Summary
Gold PPO 100/90/60 Active 50/1500 80th E&P Basic (2RJT)
01/01/2018 Summary
Gold PPO 100/90/60 Active 50/1500 80th E&P Basic Ortho (2RJS)
01/01/2018 Summary
32JN
01/01/2018
Gold PPO Voluntary 100/90/60 Active 50/1500 90th E&P Basic Ortho (32JP)
01/01/2018 Summary
Gold PPO Voluntary 100/90/60 Active 50/1500 80th E&P Basic (2RJV)
01/01/2018 Summary
Gold PPO Voluntary 100/90/60 Active 50/1500 80th E&P Basic Ortho (2RJU)
01/01/2018 Summary
Silver Dental PPO Plans
Silver PPO 100/80/50 Passive 50/1500 80th E&P Basic (2RJX)
01/01/2018 Summary
Silver PPO 100/80/50 Passive 50/1500 80th E&P Basic Ortho (2RJW)
01/01/2018 Summary
Silver PPO Voluntary 100/80/50 Passive 50/1500 80th E&P Basic (2RJZ)
01/01/2018 Summary
Silver PPO Voluntary 100/80/50 Passive 50/1500 80th E&P Basic Ortho (2RJY)
01/01/2018 Summary
Bronze Dental PPO Plans
Bronze PPO 100/80/50 Active 50/1000 MAC E&P Basic (2RK1)
01/01/2018 Summary
Bronze PPO 100/80/50 Active 50/1000 MAC E&P Basic Ortho (2RKO)
01/01/2018 Summary
Bronze PPO Voluntary 100/80/50 Active 50/1000 MAC E&P Basic (2RK3)
01/01/2018 Summary
Bronze PPO Voluntary 100/80/50 Active 50/1000 MAC E&P Basic Ortho (2RK2)
01/01/2018 Summary
2018 Blue View Vision Plans
Exam/Lense/Frame/Contact Lenses - 12/12/12/12 Plans
Full Service Plan A1
01/01/2018 Summary
Full Service Plan A2
01/01/2018 Summary
Full Service Plan A3
01/01/2018 Summary
Full Service Plan A4
01/01/2018 Summary
Full Service Plan A5
01/01/2018 Summary
Full Service Plan A6
01/01/2018 Summary
Exam/Lense/Frame/Contact Lenses - 12/12/24/12 Plans
Full Service Plan B1
01/01/2018 Summary
Full Service Plan B2
01/01/2018 Summary
Full Service Plan B3
01/01/2018 Summary
Full Service Plan B4
01/01/2018 Summary
Full Service Plan B5
01/01/2018 Summary
Full Service Plan B6
01/01/2018 Summary
Exam/Lense/Frame/Contact Lenses - 12/24/24/24 Plans
Full Service Plan C1
01/01/2018 Summary
Full Service Plan C2
01/01/2018 Summary
Full Service Plan C3
01/01/2018 Summary
Full Service Plan C4
01/01/2018 Summary
Full Service Plan C5
01/01/2018 Summary
Full Service Plan C6
01/01/2018 Summary
Full Service Plan C7
01/01/2018 Summary
Full Service Plan C8
01/01/2018 Summary
Full Service Plan C9
01/01/2018 Summary
Materials Only Plans
Materials Only Plan M01
01/01/2018 Summary
Materials Only Plan M02
01/01/2018 Summary
Materials Only Plan M03
01/01/2018 Summary
Materials Only Plan M04
01/01/2018 Summary
Materials Only Plan M05
01/01/2018 Summary
Materials Only Plan M06
01/01/2018 Summary
Form Name Effective Date Download Form
General Information
2018 Q3 & Q4 Small Group Underwriting Promotions
07/01/2018 Download
Anthem 2018 Specialty Bonus Program
02/01/2018 Download
Anthem Small Group Product Guide
01/01/2018 Download
Employer's Guide to the Premium Only Plan
01/01/2018 Download
Member Website Overview
01/01/2018 Download
PayForward FAQs
01/01/2018 Download
Provider Search Instructions
01/01/2018 Download
Resource Advisor Flyer
01/01/2018 Download
Anthem MLR Fact Sheet
09/01/2018 Download
Sample Anthem Employer MLR Check and Letter
09/01/2018 Download
Sample Anthem Employee MLR Letter
09/01/2018 Download
Medical
Anthem Medical Contract Code List
01/01/2018 Download
Anthem 2018 Medical Renewal Plan Mapping Grid
01/01/2018 Download
Anthem HMO Network Comparison Guide
01/01/2018 Download
Anthem Select PPO Flyer
01/01/2018 Download
Anthem Rx Formulary
01/01/2018 Download
Blue Card Program Flyer
01/01/2018 Download
Infertility Rider Rating Flyer
01/01/2018 Download
Live Health Online Brochure
01/01/2018 Download
Preventive Services Brochure
01/01/2018 Download
Dental
Dental Provider Nomination Form
01/01/2018 Download
Life
Travel Assist Brochure
01/01/2018 Download
Form Name Effective Date Download Form
Anthem Contact Sheet
Download