Anthem Small Group Health Insurance Forms and Documentation

Anthem

Employer Application for "Employee Elect" Plans	Employee Application for "Employee Elect" Plans
Employee Waiver	Continuation of Coverage
Overage Dependent Form	Common Law Form
Employer Application for "Benefits" Plans	Employee Application Package for "BeneFits" Plan

Employee forms can be faxed to our office at (303) 721-1085. Please confirm that application was received by calling (303) 721-1145. Please call with any questions regarding eligibility or waiting periods.

Plan Descriptions

EMPLOYEE ELECT PLANS (Brochure)
Health Plan Name	Office Visit Copay	Hospital Copay	Outpatient Copay	Prescriptions
PPO $30 Copay	$30	$500 + 20%, $3500 max	$500 + 20%, $3500 max	$15/$30/$50/30%
PPO $40 Copay	$40	$500 + 30%, $4000 max	$500 + 30%, $4000 max	$15/$30/$50/30%
PPO $35 Copay Gen Rx	$35	$500 + 30%, $3500 max	$500 + 30%, $3500 max	$15 generic only
PPO $45 Copay Gen Rx	$45	$750 + 40%, $4000 max	$750 + 40%, $4000 max	$15 generic only
Premier PPO $15 Copay	$15	$150 + 10%, $2500 max	$150 + 10%, $2500 max	$10/$30/$50/30%
Premier PPO $25 Copay	$25	$150 + 20%, $3000 max	$150 + 20%, $3000 max	$15/$30/$50/30%
Lumenos HSA 2000 Deductible	Deductible, then 100%	Deductible, then 100%	Deductible, then 100%	Deductible, then 100%
Lumenos HSA 3000 Deductible	Deductible, then 100%	Deductible, then 100%	Deductible, then 100%	Deductible, then 100%
Lumenos HSA 5000 Deductible	Deductible, then 100%	Deductible, then 100%	Deductible, then 100%	Deductible, then 100%
Lumenos HIA Plus 2000 Deductible	Deductible, then 100%	Deductible, then 100%	Deductible, then 100%	Deductible, then 100%
Lumenos HIA Plus 3000 Deductible	Deductible, then 100%	Deductible, then 100%	Deductible, then 100%	Deductible, then 100%
Classic HMO	$20	$500	$250	$15/$40/$60/30%
Premier HMO	$15	$250	$200	$10/$30/$50/30%
Classic HMO Select	$20	$500	$250	$15/$40/$60/30%
Premier HMO Select	$15	$250	$200	$10/$30/$50/30%
BENEFITS PLANS (Brochure)
Health Plan Name	Office Visit Copay	Hospital Copay	Outpatient Copay	Prescriptions
Hospital Benefits	Not Covered	Deductible & Coinsurance	Deductible & Coinsurance	$100 Deductible after Medical Ded & Coinsurance
Hospital Benefits Plus	50%	Deductible & Coinsurance	Deductible & Coinsurance	$100 Deductible after Medical Ded & Coinsurance
Hospital Benefits Preferred	50%	Deductible & Coinsurance	Deductible & Coinsurance	$100 Deductible after Medical Ded & Coinsurance
PPO $35 Copay Gen Rx	$35	$500 + 30%, $3500 max	$500 + 30%, $3500 max	$15 generic only
Lumenos HSA 3000 Deductible	Deductible, then 100%	Deductible, then 100%	Deductible, then 100%	Deductible, then 100%
Classic HMO Select	$20	$500	$250	$15/$40/$60/30%

State Mandated Plans

Health Plan Name	Office Visit Copay	Hospital Copay	Outpatient Copay
Basic HMO	$30	$400/day, max $1600	$150
Standard HMO	$20	$150/day, max $600	$50
Basic PPO	$30	$3000 deductible + 30%, $5000 max	$3000 deductible + 30%, $5000 max
Standard PPO	$30	$1000 deductible + 20%, $2000 max	$1000 deductible + 20%, $2000 max

Discontinued Plans

The following plans were discontinued by Anthem as of 10-31-05. Some plans may be renewed in 2006, other plans will have to be converted to a new plan design. Please call (303) 721-1145 for details.

BluePreferred PPO Plans

Plan Name	Office Visit Copay	Deductible	Coinsurance
Plan A	$15	$0	10% to $1K + copays
Plan I	$25	$0	20% to $2K + copays
Plan J	$25	$0	20% to $2K + copays