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The following is a list of sales literature and enrollment forms available in a PDF format. To print a single form, click on the form name and it will opena printablePDF file.To order a larger supply,log on and usethe Order Form located on the upper left menu. Note: To print a PDF document, you need Adobe® Acrobat® Reader. Download it now for free.

Quick Links: Plans effective 1-1-14 and after
Plans effective before 1-1-14

Form Name Form #

Plans effective 1-1-14 and after

SALES LITERATURE

Individual - Medical

 
2015 Medical Plans for Individuals 3-1021
2015 ConnectedCare Plans Guide 3-191
2015 Cost-Sharing Plans Guide 3-190
2015 Tribal Plans for Individuals 3-1031
2015 Bronze Plans Guide 3-192
2015 Silver Plans Guide 3-193
2015 Gold and Platinum Plans Guide 3-194
2014 Individual Product Plan Guide 3-1016
Short Term PPOsm Brochure & Application 3-614
Spanish Short Term PPOsm Brochure 3-614SP
Short Term PPO - Rate Card (Rates effective 8/1/2015 through 10/31/2015) 3-423
Short Term PPO - Rate Card (Rates effective 5/1/2015 through 7/31/2015) 3-423
Brochure: Individual Additional Benefits (Brining You More) 3-1114

Individual - Dental

 
2015 Individual Dental Plans 3-187
Individual QHP Dental Choice & Dental Choice Plus Plans and Application 3-189
Individual QHP Plan; Dental Choice & Dental Choice Plus Application 3-189A
Healthy SmilesSM Brochure and Application 3-052
Healthy SmilesSM Application 3-052a
Healthy SmilesSM Rates Card 3-076
Healthy Smiles Dental Maximum Carryover 3-078

Small Group (2-50 employees)

 
2015 Small Group Product Plan Guide 3-1022

Group Dental

 
Group Dental Plans 3-765

Ancillary Products

 
Employee Assistance Program 3-360
Nurse Advice Line 3-613
Premium Only Plan 3-225
VSP – Plan C-I 3-425
VSP – Plan C-II 3-426
VSP – Plan C-III 3-427
VSP - Voluntary (12/12) $10/25 Copay 3-353
VSP - Voluntary (12/12) $20/25 Copay 3-354
VSP - Voluntary (12/24) $10/25 Copay 3-355
VSP - Voluntary (12/24) $20/25 Copay 3-359
VSP - Exam Only/$10 3-370
VSP - Exam Only/$20 3-371
VSP - Exam Only/$25 3-374
VSP - Exam with Allowance $100/12 3-361
VSP - Exam with Allowance $125/12 3-363
VSP - Exam with Allowance $150/12 3-364
VSP - Exam with Allowance $100/24 3-365
VSP - Exam with Allowance $125/24 3-367
VSP - Exam with Allowance $150/24 3-368
VSP Flyer for Prime 65 Plans F,K, M & N 4-164
ENROLLMENT FORMS (eff 1-1-14 & after)  

Individual

   
Individual Universal Application and Cover Letter 3-397
QHP Products Change Form 3-929
Authorization Agreement for Prearranged Payments  3-449
Spanish Short Term PPO Application  3-614A SP

Small Group (2-50 employees)

 

Employer Application and Group Questionnaire for New Groups 2-50 Employees

3-549
Universal Idaho Small Employer Application 3-017
Employee's Waiver of Coverage 3-467

Medium Group (51-99 employees)

 
Application Cover Sheet for Group Dual Option (HSA) 3-128
Idaho Large Group Application Cover Sheet 3-186A
Idaho Large Group Application 3-186
Employer Application and Group Questionnaire for New Groups 51 or more Employees 3-550
Employee's Waiver of Coverage 3-467
Large Group Health Application without Health Statement 3-556

Large Group (100+ employees)

 
Application Cover Sheet for Group Dual Option (HSA) 3-128
Idaho Large Group Application Cover Sheet 3-186A
Idaho Large Group Application 3-186
Employer Application and Group Questionnaire for New Groups 51 or more Employees 3-550
Employee's Waiver of Coverage 3-467
Large Group Health Application without Health Statement 3-556
Large Group Health/Dental Application without Health Statement 3-393
ASC Group Health Enrollment Application 3-305
ASC Group Health/Dental Enrollment Application 3-307
SWS ASC Enrollment Form
3-307 SWS

Group Dental

Group Dual Option Dental Application 3-295

Ancillary

 
Group Voluntary Vision Enrollment Application 3-412
 
OTHER FORMS AND BROCHURES  
Nonsmoker Certification 3-319

Plans effective before 1-1-14

SALES LITERATURE

Individual - Medical

 
Short Term PPO - Rate Card 3-423
BlueCare® PPOBrochure 3-323
ConnectedCareSM Brochure 3-973
Essential BlueSM Brochure 3-136
Essential BlueSM Plus Brochure 3-144
HSA BlueSM PPO Brochure 3-296
Simply Blue Brochure 3-622
Individual Program Premiums - RL1 eff 11-1-13 3-431
Prime 65sm Medicare Supplement Brochure 3-023
Prime 65 Comparison 3-038
State Mandated High Risk Pool (HRP) products 3-313

Small Group (2-50 employees)

 
Small Group Overview 3-734
Connected Care Brochure 3-328
Healthy Measures 3-121

Medium/Large Group (51+ employees)

 
Large Group Overview 3-733
Connected Care Brochure 3-328
Healthy Measures 3-121

Group Dental

 
Group Dental Plans 3-765

Ancillary Products

 
Employee Assistance Program 3-360
Nurse Advice Line 3-613
Premium Only Plan 3-225
VSP – Plan C-I 3-425
VSP – Plan C-II 3-426
VSP – Plan C-III 3-427
VSP - Voluntary (12/12) $10/25 Copay 3-353
VSP - Voluntary (12/12) $20/25 Copay 3-354
VSP - Voluntary (12/24) $10/25 Copay 3-355
VSP - Voluntary (12/24) $20/25 Copay 3-359
VSP - Exam Only/$10 3-370
VSP - Exam Only/$20 3-371
VSP - Exam Only/$25 3-374
VSP - Exam with Allowance $100/12 3-361
VSP - Exam with Allowance $125/12 3-363
VSP - Exam with Allowance $150/12 3-364
VSP - Exam with Allowance $100/24 3-365
VSP - Exam with Allowance $125/24 3-367
VSP - Exam with Allowance $150/24 3-368
VSP Flyer for Prime 65 Plans F,K, M & N 4-164
ENROLLMENT FORMS

Individual

 
Individual Universal Application 3-397
Notice to Applicant 6-111a
Transfer Application 3-362
Individual Health Insurance Coverage Change Form 3-356CS
Short Term PPO Application 3-614A
Split Application Authorization Form 3-665
Authorization to Delete Dependent N/A
Authorization Agreement for Prearranged Payments 3-449

Small Group (2-50 employees)

 
Checklist for Enrolling/Changing Small Groups (2-50) None
Employee Census Data 3-468
Idaho Small Employer Application Cover Sheet 3-366
Universal Idaho Small Employer Application 3-017
Employee's Waiver of Health Care Coverage 3-467
Letter of Record 3-302
Managed Care Group Questionnaire for New Groups 2-50 Employees 3-242
Application Cover Sheet for Group Dual Option (HSA) 3-128
SBC Attestation 3-325

Medium Group (51-99 employees)

 
Checklist for Enrolling Large Groups - Size 51-99 None
Group Questionnaire for New Groups - 51 or more employees 3-471
Employee Census Data 3-468
Application for Medium/Large Employer Coverage 3-326
Large Group Health Application with Health Statement 3-300
Large Group Health/Dental Enrollment Application with Health Statement 3-301
Large Group Health Application without Health Statement 3-556
Employee's Waiver of Health Care Coverage 3-467
Letter of Record 3-302
Application Cover Sheet for Group Dual Option (HSA) 3-128
SBC Attestation 3-325

Large Group (100+ employees)

 
Group Questionnaire for New Groups - 51 or more employees 3-471
Employee Census Data 3-468
Application for Medium/Large Employer Coverage 3-326
Employee's Waiver of Health Care Coverage 3-467
Letter of Record 3-302
Application Cover Sheet for Group Dual Option (HSA) 3-128
Large Group Health Application with Health Statement 3-300
Large Group Health Application without Health Statement 3-556
Large Group Health/Dental Enrollment Application with Health Statement 3-301
Large Group Health/Dental Application without Health Statement 3-393
ASC Application/ Questionnaire for New Groups 3-437
ASC Group Health Enrollment Application 3-305
ASC Group Health/Dental Enrollment Application 3-307
SWS ASC Enrollment Form 3-307 SWS
Managed Care Group Questionnaire for New Groups 51 or More Employees 3-243
Managed Care ASC Application/Questionnaire for New Groups 3-244
SBC Attestation 3-325

Ancillary

 
Healthy Smiles Dental Application 3-052A
Dental Enrollment Application 3-395
Group Voluntary Dental and/or Vision Employer Application 3-309
Group Voluntary Vision Enrollment Application 3-412
Individual Dental Coverage Change Form 3-106
Premium Only Plan (POP) Enrollment Application 3-225a