| Form Name | Effective Date | Download Form |
|---|---|---|
|
New Group Submission |
||
|
Employer Application 1.21 |
01/01/2021 | Download |
|
ACH Authorization Form |
01/01/2021 | Download |
|
Corporate Officer/Proprietor/Partner Verification Statement |
01/01/2021 | Download |
| Form Name | Effective Date | Download Form |
|---|---|---|
|
Enrollment and Change Forms |
||
|
Employee Enrollment & Change Form 1.21 |
01/01/2021 | Download |
|
Employee Waiver Form 1.21 |
01/01/2021 | Download |
| Form Name | Effective Date | Download Form | |
|---|---|---|---|
|
2021 Medical EPO |
|||
|
LocalPlus Network |
|||
|
LocalPlus Platinum 0 Option 1 |
01/01/2021 | Summary | SBC |
|
LocalPlus Platinum 0 Option 1 INF |
01/01/2021 | Summary | SBC |
|
LocalPlus Platinum 0 Option 2 |
01/01/2021 | Summary | SBC |
|
LocalPlus Platinum 0 Option 2 INF |
01/01/2021 | Summary | SBC |
|
LocalPlus Platinum 250 |
01/01/2021 | Summary | SBC |
|
LocalPlus Platinum 250 INF |
01/01/2021 | Summary | SBC |
|
LocalPlus Platinum 500 |
01/01/2021 | Summary | SBC |
|
LocalPlus Platinum 500 INF |
01/01/2021 | Summary | SBC |
|
LocalPlus Gold 0 |
01/01/2021 | Summary | SBC |
|
LocalPlus Gold 0 INF |
01/01/2021 | Summary | SBC |
|
LocalPlus Gold 250 |
01/01/2021 | Summary | SBC |
|
LocalPlus Gold 250 INF |
01/01/2021 | Summary | SBC |
|
LocalPlus Gold 750 |
01/01/2021 | Summary | SBC |
|
LocalPlus Gold 750 INF |
01/01/2021 | Summary | SBC |
|
LocalPlus Gold 1200 |
01/01/2021 | Summary | SBC |
|
LocalPlus Gold 1200 INF |
01/01/2021 | Summary | SBC |
|
LocalPlus Silver 1700 |
01/01/2021 | Summary | SBC |
|
LocalPlus Silver 1700 INF |
01/01/2021 | Summary | SBC |
|
LocalPlus Silver 2000 |
01/01/2021 | Summary | SBC |
|
LocalPlus Silver 2000 INF |
01/01/2021 | Summary | SBC |
|
LocalPlus Silver 2250 Option 1 |
01/01/2021 | Summary | SBC |
|
LocalPlus Silver 2250 Option 1 INF |
01/01/2021 | Summary | SBC |
|
LocalPlus Silver 2250 Option 2 |
01/01/2021 | Summary | SBC |
|
LocalPlus Silver 2250 Option 2 INF |
01/01/2021 | Summary | SBC |
|
LocalPlus Bronze 6000 |
01/01/2021 | Summary | SBC |
|
LocalPlus Bronze 6000 INF |
01/01/2021 | Summary | SBC |
|
LocalPlus Bronze 6300 |
01/01/2021 | Summary | SBC |
|
LocalPlus Bronze 6300 INF |
01/01/2021 | Summary | SBC |
|
LocalPlus Bronze 5500 HSA |
01/01/2021 | Summary | SBC |
|
LocalPlus Bronze 5500 HSA INF |
01/01/2021 | Summary | SBC |
|
LocalPlus Bronze 6500 HSA |
01/01/2021 | Summary | SBC |
|
LocalPlus Bronze 6500 HSA INF |
01/01/2021 | Summary | SBC |
|
Open Access Plus Network |
|||
|
Open Access Plus Platinum 0 Option 1 |
01/01/2021 | Summary | SBC |
|
Open Access Plus Platinum 0 Option 1 INF |
01/01/2021 | Summary | SBC |
|
Open Access Plus Platinum 0 Option 2 |
01/01/2021 | Summary | SBC |
|
Open Access Plus Platinum 0 Option 2 INF |
01/01/2021 | Summary | SBC |
|
Open Access Plus Platinum 250 |
01/01/2021 | Summary | SBC |
|
Open Access Plus Platinum 250 INF |
01/01/2021 | Summary | SBC |
|
Open Access Plus Platinum 500 |
01/01/2021 | Summary | SBC |
|
Open Access Plus Platinum 500 INF |
01/01/2021 | Summary | SBC |
|
Open Access Plus Gold 0 |
01/01/2021 | Summary | SBC |
|
Open Access Plus Gold 0 INF |
01/01/2021 | Summary | SBC |
|
Open Access Plus Gold 250 |
01/01/2021 | Summary | SBC |
|
Open Access Plus Gold 250 INF |
01/01/2021 | Summary | SBC |
|
Open Access Plus Gold 750 |
01/01/2021 | Summary | SBC |
|
Open Access Plus Gold 750 INF |
01/01/2021 | Summary | SBC |
|
Open Access Plus Gold 1200 |
01/01/2021 | Summary | SBC |
|
Open Access Plus Gold 1200 INF |
01/01/2021 | Summary | SBC |
|
Open Access Plus Silver 1700 |
01/01/2021 | Summary | SBC |
|
Open Access Plus Silver 1700 INF |
01/01/2021 | Summary | SBC |
|
Open Access Plus Silver 2000 |
01/01/2021 | Summary | SBC |
|
Open Access Plus Silver 2000 INF |
01/01/2021 | Summary | SBC |
|
Open Access Plus Silver 2250 Option 1 |
01/01/2021 | Summary | SBC |
|
Open Access Plus Silver 2250 Option 1 INF |
01/01/2021 | Summary | SBC |
|
Open Access Plus Silver 2250 Option 2 |
01/01/2021 | Summary | SBC |
|
Open Access Plus Silver 2250 Option 2 INF |
01/01/2021 | Summary | SBC |
|
Open Access Plus Bronze 6000 |
01/01/2021 | Summary | SBC |
|
Open Access Plus Bronze 6000 INF |
01/01/2021 | Summary | SBC |
|
Open Access Plus Bronze 6300 |
01/01/2021 | Summary | SBC |
|
Open Access Plus Bronze 6300 INF |
01/01/2021 | Summary | SBC |
|
Open Access Plus Bronze 5500 HSA |
01/01/2021 | Summary | SBC |
|
Open Access Plus Bronze 5500 HSA INF |
01/01/2021 | Summary | SBC |
|
Open Access Plus Bronze 6500 HSA |
01/01/2021 | Summary | SBC |
|
Open Access Plus Bronze 6500 HSA INF |
01/01/2021 | Summary | SBC |
| Form Name | Effective Date | Download Form |
|---|---|---|
|
Under Construction |
| Form Name | Effective Date | Download Form |
|---|
