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Small Group Forms

PW_A075367
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Table of Contents
Health Plan Summary of Benefits
These health plans are available for new and renewing gropus on or after January 1, 
EmployeeElect Health Plans
Basic and Standard Health Plans
Dental and Visions Benefit Summaries
These plans are available to groups with 2-50 employees. 

Dental Plan Benefits Summaries

Vision Plan Benefits Summaries

Other Health Summary of Benefits (for renewing business only)
Note: The products listed below are no longer available for new business; information is provided for renewing business only. These plans do contain the January 1, 2010 benefit modifications and are effective on the group renewal date.

EmployeeElect

High Deductible Health Plans (HAS Compatible) - HDHP with RX

High Deductible Health Plans (HAS Compatible) – HDHP with no RX

HMO BlueAdvantage

PPO BluePrefered

Nevada Advantage

Address Change Form

Part D for Small Groups – Creditable/Non – Creditable Plans

Part D Downloadable Templates

Health Plan Comparison Guide

Group Prescreen Form

Enrollment and Change Forms
Nevada Small Group EmployeeElect Life Plan Renewal Change Request Form 
HMO Employer Enrollment Application/Change Form ( For 10/01/09 and later plans) 
PPO Employer Enrollment Application/Change Form ( For 10/01/09 and later plans) 
Application and change form for enrolment and/or changes in health, dental, vision, life and disability coverage. 
HMO Employee Enrollment Application/Change Form (For 10/01/09 and later plans) 
PPO Employee Enrollment Application/Change Form ( For 10/01/09 and later plans) 
May be used by employees for enrollment and/or changes in health, dental, vision, life and disability coverage. 
This form authorizes Anthem to release a member’s medical information to the person listed on the form. 
This form authorizes Anthem to release a member’s psychotherapy notes to the person listed on the form. 
To avoid disruption for a member currently under a provider’s care; approved on a case by case basis up to 90 days in advance. 
Use the Anthem Life website to access/download Anthem Life forms. 
For requesting continuation of health coverage when a member/dependent terminates coverage with the group. Spanish version of this form
 
Anthem Blue Cross and Blue Shield now offers a special package of programs for small group employers who are members of the Las Vegas Latin Chamber of Commerce 
Pharmacy Forms
Home Delivery Pharmacy Order Form
Prescription Drug Claim Form

To find these forms, members must visit the Express Scripts website after login to their health plan site. Click the link in the Refill a Prescription section after login. On the Express Scripts site, select these forms from the Printable Forms section. 
 
To order supplies please log into Agent Services 
©2005-2014 copyright of Anthem Insurance Companies, Inc.

Anthem Blue Cross and Blue Shield is the trade name of: In Colorado Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Com pany. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin ("BCBSWi"), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare"), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Use of the Anthem Web sites constitutes your agreement with our Terms of Use