Plan Brochure Health Plan Outlines Rx Plan Outlines Dental Plan Outlines New Business Enrollment Forms General Information Claim Forms

Plan Brochure

• [PB100-01-51909] Plan Brochure (Pages)
• [PB110-01-020210] Dental Options


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Health Plan Outlines

• [PB001-01-021710] Diamond Plan Outline
• [PB002-01-021710] Gold Plan Outline
• [PB002-01-021710] Silver Plan Outline
• [PB004-01-021710] Bronze Plan Outline
• [PB005-01-021710] HRA Simple 2000 Plan Outline
• [PB006-01-021710] HRA Simple 3000 Plan Outline
• [PB007-01-021710] HRA Simple 4000 Plan Outline
• [PB008-01-021710] HRA Simple 5000 Plan Outline
• [PB009-01-021710] Investors Choice 1200 Plan Outline
• [PB010-01-021710] Investors Choice 2000 Plan Outline
• [PB011-01-021710] Investors Choice Simple 2500 Plan Outline
• [PB012-01-021710] Investors Choice Simple 5500 Plan Outline


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Rx Plan Outlines

• [Rx001-01-82508] Rx Drug Benefit - Option 1
• [Rx002-01-82508] Rx Drug Benefit - Option 2
• [Rx003-01-82508] Rx Drug Benefit - Option 3
• [Rx004-01-51809] Rx Drug Benefit - Option 4


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Dental Plan Outlines

• [DT001-01-020210] Dental PPO 25
• [DT002-01-020210] Dental PPO 50
• [DT003-01-020210] Dental PPO 100


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New Business

• [NB010-01-012510] Prospect Process
• [NB030-01-030110] Underwriting Process
• [NB040-01-120109] Self-Funding 101
• [NB050-01-012810] New Business Checklist


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Enrollment Forms

• [EF020-01-111909] Plan Service Agreement
• [EF028-01-012810] NY Surcharge - Employer Statement and Application
• [EF040-01-121409] Employee Enrollment Form under 51 lives
• [EF045-01-121409] Employee Enrollment Form 51+ Lives
• [EF048-01-120109] 1099 Applicant Verification Form
• [EF050-01-121709] Medical Coverage Waiver
• [EF060-01-121709] Enrollment Change Form


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General Information

• [GI010-01-042009] Questions and Answers
• [GI030-01-61108] MutiPlan-PHCS Downloadable Provider Directories
• [GI050-01-61708] MultiPlan Network - Fact Sheet
• [GI080-01-71509] PHCS Urgent Care-Lab & Diagnostics (MD)
• [GI080-02-71509] ONENET Urgent Care-Lab & Diagnostics (MD)
• [GI090-01-050809] OneNet PPO
• [GI091-01-051109] OneNet PPO - Service Area Map
• [GI100-01-120109] Renewal Requirements


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Claim Forms

• CVSCaremark Prescription Reimbursement Standard Claim Form


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