EmployerAccess Login
Not Registered?
Small Groups Register Now.
Large Groups, please contact your Account Representative.

Login by Selecting:

Login
Find a Doctor
Search our provider directory when you need a doctor, hospital, pharmacy or other health care provider.

360° Health®
A total-health solution that surrounds everyone with the help they need to live healthier, feel better and save money doing it.

Learn More

Anthem HSA-qualified High-deductible Health Plan Description Forms

PW_A072241
Table of Contents
 
Health Plan Description Forms:
BlueAdvantage HMO Health Plans
HMOSelect™ Health Plans
BlueFreedom Health Plans
BluePreferred PPO Health Plans
PPO with HSA-qualified Health Plans
Multi-option Packages
 
Dental Plan Benefits Summaries
Anthem Blue Dental PPO and PPO Plus Plans
Anthem Blue Dental PPO and PPO Plus Voluntary Plans
 
Vision Plan Benefits Summaries
Anthem Vision Plans: Please call Large Group Sales at 303-831-2077 for assistance.
Blue View Vision Comprehensive Plans
Blue View Vision Exam-only Plans
Blue View Vision Materials-only Plans
 
Enrollment Applications and Change Forms
Employer Application/Change Form - Application and change form for employer’s group health, dental and/or vision coverage. 
Employee Enrollment Application/Change Form - May be used by employees for enrollment and/or changes in large group health, dental, vision, life and disability coverage. Download this form in Spanish 
Affidavit of Common-law Marriage - For adding a common-law spouse and his/her dependents to a policy. Download this form in Spanish 
Continuity of Care 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. 
Overage Dependent Form - For enrollment/continuation of coverage for overage dependents. Download this form in Spanish 
Mentally or Physically Disabled Dependent Enrollment Request - Submit with enrollment application if you have an overage physically or mentally disabled dependent.
Download this form in Spanish
 
Waiver of Insurance - To waive insurance benefits when not using the Employee Enrollment Application/Change Form. Download this form in Spanish 
COBRA/State Continuation of Coverage - For requesting continuation of health coverage when a member/dependent coverage is terminated. Download this form in Spanish 
Anthem Life Insurance Forms - Use the Anthem Life website to access/download Anthem Life forms (other than enrollment application/change form).  
 
 
Member Forms - General
Individual Authorization Form - This form authorizes Anthem to release a member’s medical information to the person listed on the form.  
Psychotherapy Notes Authorization Form - This form authorizes Anthem to release a member’s psychotherapy notes to the person listed on the form.  
 
 
Health Plan Description Forms
BlueAdvantage HMO Health Plans 
 
HMOSelect™  
 
BlueFreedom Health Plans 
BluePreferred PPO Health Plans 
 
PPO with HSA-qualified Health Plans 
 
Multi-option Health Plans 
 
Dental Plan Benefits Summaries
Anthem Blue Dental PPO and PPO Plus Plans 
 
Anthem Blue Dental PPO and PPO Plus Voluntary Plans 
 
Vision Plan Benefits Summaries 
Blue View Vision Comprehensive Plans 
 
Blue View Vision Exam-only Plans 
 
Blue View Vision Materials-only Plans 
 
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. 
©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