Agent Supply Request Form Colorado

Transcription

1 Agent Supply Request Form Colorado Individual & Small Group (ISG) Sales Materials FAX completed request to: or toll-free ISG Sales Support can be reached at or toll-free or Date: Agent/Agency Encrypted TIN #: Anthem Broker #: Phone Number: FAX Number: Company Name: Attention: Street Address: (Physical address required - We will not ship to a P.O. Box) City, State, Zip Check One: Residence Office Check here if this is a one-time mailing INDIVIDUAL PRODUCTS Colorado BluePreferred Enrollment Materials Enrollment Kit for BluePreferred BluePreferred Brochure 262b (1/04) Business Reply Envelope 863-B (3/04) 96329K BluePreferred Rates for Health Plan Description Form (3/05) Personalized Health Quote Envelope b BluePreferred for Individuals Brochure 863-B Business Reply Envelope for Individual Apps BluePreferred Rates for Health Plan Description Form Roll-up RightPlan PPO 40 Enrollment Kit for RightPlan PPO 40 Personalized Health Quote Envelope 986 RPPO40 CO Right Plan PPO 40 Brochure RightPlan Health Plan Description No RX CIM DL93 RightPlan Health Plan Description Generic Rx CIM DL94 RightPlan Health Plan Description Full RX CIM DL CO Right Plan PPO 40 Brochure (rates included) CIM RightPlan Health Plan Description No RX DL CIM RightPlan Health Plan Description Generic Rx DL CIM RightPlan Health Plan Description Full RX DL95 Lumenos CDHPs HSALUM Enrollment Kit for Lumenos HSA Personalized Health Quote Envelope 986 Your HSA with Melon Lumenos Health Savings Account Product Brochure Lumenos FAQ Individual HSA Please allow 7 days for delivery Case Study HSA Adams-Smiths Lumenos HSA Individual Rates Colorado HSA roll up Your HSA with Mellon Lumenos Health Savings Account Product Brochure Lumenos FAQ Individual HSA Case Study HSA Adams Smiths Lumenos HSA Individual Rates Colorado HSA roll-up Enrollment Kit for Lumenos HIA Personalized Health Quote Envelope 986 HIALUM Lumenos Health Incentive Account Product Brochure Case Study HIA Jones Livingstons Lumenos FAQ Individual HIA Lumenos HIA Individual Rates Co HIA roll up Lumenos Health Incentive Account Product Brochure Case Study HIA Jones Livingstons Lumenos FAQ Individual HIA Lumenos HIA Individual Rates Lumenos HIA 3000D/ % Health Plan Description CO HIA roll up O:\Agent Support - ISG\Forms - Miscellaneous\Supply Order Forms\Agent SRF Colorado EXTERNAL USE.doc Revised 07/26/2007 Page 1 of 6

2 Enrollment Kit for Lumenos HIA Plus Personalized Health Quote Envelope 986 Lumenos Health Incentive Account Plus HIAPLUS Product Brochure Case Study HIA Plus Adams Smiths Lumenos FAQ Individual HIA Plus Lumenos HIA-Plus Individual Rates Co HIA Plus roll up Lumenos Health Incentive Account Plus Product Brochure Case Study HIA Plus Adams Smiths Lumenos FAQ Individual HIA Plus Lumenos HIA Plus Individual Rates Co HIA Plus roll up Individual Specialty Products CO Specialty Rate Sheet for Agents/Dental and Term Life Rates CO Anthem Blue Dental Plan Flyer CO Blue Dental Plan Brochure with application CO Anthem Dental Application-standalone CO Anthem Life-Term Insurance Flyer CO Anthem Life Insurance Tri Fold Brochure Tonik Individual Products Tonik Direct Mailer Cover you re A-Z (09/05) This form limited to BlueStar brokers only (12-06) Tonik Member Brochure: Get Hooked Up (12-06)) Tonik Marketing Insert: It s all about you (12-06) Tonik Agent Guide: Selling at the Speed of Tonik (12-06) Colorado Individual Agent Guide Agent Resource Guide RightPlan Rates You Choose Lumenos Individual and Family Health Plans CO 2007 Ind Bonus Program Brochure SMALL GROUP PRODUCTS Colorado EmployeeElect Enrollment Materials EmployeeElect Enrollment Kit for Employers EmployeeElect Comparison EmployeeElect PPO rollup EmployeeElect Lumenos rollup ELECT EmployeeElect HMO rollup AnthemRewards Flyer 4187EST Employer Master Contract Employer Enrollment App Employee Enrollment App Specialty Products App CO Individual Products Agent Information SP- Don t get caught uninsured slick CO Co Ind Plan Option Table Anthem Life & Disability Guide Anthem Dental Plans Guide Blue View Vision Plan Guide CO POP Tax Savings Overview Premium Only Plan Application Anthem.com Overview (7/04) Special Anthem Poster MBCEPST-98 MyHealth@Anthem Overview MBNACESHT- Chiropractic Benefits Overview Care Outside Colorado (HMO Only) 980 Open access overview (HMO Only) BlueCard Program (PPO Only) HMOSelect Network Flyer How to Find Providers order form Subscriber Submitted Claim form CO COBRA or State Continuation App Affidavit of Common Law Marriage Continuity of Care Form Sales at a Glance HIA Plus Sales at a Glance-HSA HSA with Mellon Group Administrator Guide HIA Plus Case Study Livingston Family HIA Plus Case Study Mary Jones HIA Plus Case Study Steve Adams HIA Plus Case Study- Smiths Family Lumenos FAQ HIA Plus Introductory Education Brochure HIA Plus EmployeeElect Comparison Guide EmployeeElect PPO rollup EmployeeElect HSA Lumenos rollup EmployeeElect HMO rollup 4187EST Anthem Rewards Flyer Employer Master Contract Employer Enrollment App Employee Enrollment App Anthem Life & Disability Guide Anthem Dental Plans Guide Blue View Vision Plan Guide POP Tax Savings Overview Premium only Plan Application Anthem.com Overview (7/04) MBCEPST-98 Special Anthem Poster MBNACESHT- MyHealth@Anthem Overview PBM-32 NextRX Mail Order Form Chiropractic Benefits Overview 980 Care Outside of Colorado (HMO Only) Open access overview (HMO Only) BlueCard Program (PPO Only) HMO Select Network Flyer How to Find Providers order form CO Subscriber Submitted Claim form O:\Agent Support - ISG\Forms - Miscellaneous\Supply Order Forms\Agent SRF Colorado EXTERNAL USE.doc Revised 07/26/2007 Page 2 of 6

3 94044 COBRA or State Continuation App Affidavit of Common Law Marriage Continuity of Care Form Sales at a Glance HIA Plus Sales at a Glance HSA HSA with Mellon Group Administrator Guide Consumer Brochure HIA Plus Case Study Livingston Family HIA Plus Case Study Mary Jones HIA Plus Case Study Steve Adams HIA Plus Case Study Smiths Family Lumenos FAQ-HIA Plus Introductory Education Brochure HIA Plus Your HSA with Mellon Flier Lumenos FAQ-HSA LUMSPE Lumenos Sales Packet for Employee Elect (included in 01-Elect Packet) Sales at a Glance HIA Plus Sales at a Glance-HSA HSA with Mellon Group Administrator Guide Sales at a Glance HIA Plus Sales at a Glance HSA HSA with Mellon Group Administrator Guide LUMCNE Lumenos Consumer Packet for Employee Elect(included in 01- Elect packet) HIA Plus Case Study Livingston Family HIA Plus Case Study Mary Jones HIA Plus Case Study Steve Adams HIA Plus Case Study- Smiths Family Lumenos FAQ HIA Plus Introductory Education Brochure HIA Plus Consumer Brochure Preventive Care Glier HIA Plus Case Study Livingston Family HIA Plus Case Study Mary Jones HIA Plus Case Study Steve Adams HIA Plus Case Study- Smiths Family Lumenos FAQ HIA Plus Introductory Education Brochure HIA Plus Lumenos FAQ-HSA EmployeeElect Enrollment Kit for Employees Employee Enrollment App ELECT Specialty Products App Anthem.com Overview Special Anthem Overview MBNACESHT-22 HMOSelect Network Flyer Anthem Rewards Employee Enrollment App Anthem.com Overview MBNACESHT- Special Anthem Overview 22 PBM-32 NextRX Mail Order Form HMO Select Network Flyer 7516 Anthem Rewards EmployeeElect Lumenos HIA Plus HIA Plus Case Study Livingston Family LUMHIA HIA Plus HIA Plus Case Study Mary Jones HIA Plus Case Study Steve Adams HIA Plus Case Study Smith Family Lumenos FAQ-HIA Plus Introductory Education Brochure HIA Plus HIA Plus Case Study Livingston Family HIA Plus Case Study Mary Jones HIA Plus Case Study Steve Adams HIA Plus Case Study Smith Family Lumenos FAQ HIA Plus Introductory Education Brochure HIA Plus EmployeeElect Lumenos HSA LUMHSA Introductory Education Brochure-HSA Lumenos FAQ HSA O:\Agent Support - ISG\Forms - Miscellaneous\Supply Order Forms\Agent SRF Colorado EXTERNAL USE.doc Revised 07/26/2007 Page 3 of 6

4 Employee Elect Lumenos Brochures PPO $45 Copay GenRx Plan PPO $35 Copay GenRx Plan PPO $40 Copay Plan PPO $30 Copay Plan Premier PPO $25 Copay Plan Premier PPO $15 Copay Plan Classic HMOSelect Plan Premier HMOSelect Plan Classic HMO Plan Premier HMO Plan Lumenos HIA Plus Lumenos HIA Plus Lumenos HSA Lumenos HSA Lumenos HSA 5000 Colorado BeneFits Enrollment Materials Colorado BeneFits Enrollment Kit for Employers BeneFits Master Contract BeneFits Employer Enrollment App BeneFits Employee Enrollment App 03-BENE Specialty Products App BeneFits Comparison Guide Hospital BeneFits Preferred Plan Description CMS BA87 Hospital BeneFits Plan Description CSM BA85 Hospital BeneFits Plus Plan Description CSM BA86 Classic HMOSelect Plan Description BA80 BA89 PPO $35 Copay GenRX Plan Description BA73 BA88 Lumenos HSA 2000 Plan Description Lumenos HSA 3000 Plan Description Lumenos HSA 5000 Plan Description HMOSelect Flyer AnthemRewards Flyer 4187EST Anthem Life & Disability Guide Anthem Dental Plans Guide Blue View Vision Plan Guide CO POP Tax Savings Overview Premium only Plan Application Anthem.com Overview (7/04) Special Anthem Poster MBCEPST-98 MyHealth@Anthem Overview MBNACESHT- Chiropractic Benefits Overview Care Outside Colorado (HMO Only) 980 Open access overview (HMO Only) BlueCard Program (PPO Only) How to Find Providers order form Subscriber Submitted Claim form CO COBRA or State Continuation App Affidavit of Common Law Marriage Continuity of Care Form Sales at a Glance HSA HSA with Mellon Group Administrator Guide BeneFits Master Contract BeneFits Employer Enrollment App BeneFits Employee Enrollment App BeneFits Comparison Guide CSM Hospital BeneFits Preferred Plan Description BA CSM Hospital BeneFits Plan Description BA CSM Hospital BeneFits Plus Plan Description BA BA80 Classic HMO Select Plan Description BA73 PPO $35 Copay GenRX Plan Description Lumenos HSA 2000 Plan Description Lumenos HSA 3000 Plan Description Lumenos HSA 5000 Plan Description HMOSelect Network Flyer 4187-EST AnthemRewards Flyer Anthem Life & Disability Guide Anthem Dental Plans Guide CO Blue View Vision Plan Guide POP Tax Savings Overview Premium only Plan Application 98646(7/04) Anthem.com Overview MBCEPST-98 Special Anthem Poster MBNACESHT- MyHealth@Anthem Overview PBM-32 NextRX Mail Order Form Chiropractic Benefits Overview 980 Care Outside Colorado (HMO only) Open Access Overview (HMO only) BlueCard Program (PPO Only) How to Find Providers order form CO Subscriber Submitted Claim form COBRA or State Continuation App Affidavit of Common Law Marriage Continuity of Care Form HSA Sales at a Glance HSA With Mellon Group Administrator Guide Consumer Brochure Introductory Education Brochure Lumenos FAQ HSA O:\Agent Support - ISG\Forms - Miscellaneous\Supply Order Forms\Agent SRF Colorado EXTERNAL USE.doc Revised 07/26/2007 Page 4 of 6

5 LUMSPB Lumenos Sales Packet For BeneFits (included in 03-Bene Packet) Sales at a Glance HSA HSA with Mellon Group Administrator Guide Sales at a Glance HSA HSA with Mellon Group Administrator Guide LUMCNB 02-BENE Lumenos Consumer Packet for BeneFits (included in 03-Benet Packet) Consumer Brochure Preventive Care Flier Web Information Flier HSA Case Study Steve Adams HSA Case Study Smiths Family Your HSA with Millon Flier Lumenos FAQ-HSA Colorado BeneFits Enrollment Kit for Employees BeneFits Employee Enrollment App Specialty Products App HMOSelect Flyer Anthem.com Overview Special Anthem Overview MBNACESHT-22 Anthem Rewards BeneFits Employee Enrollment App HMOSelect Network Flyer Anthem.com Overview PBM-32 NextRX Mail Order Form 7516 Anthem Rewards BENELUM BeneFits Lumenos Preventive Care Flier Form Web Information Flier Lumenos FAQ HSA Form Web Information Flier Lumenos FAQ HSA Colorado Small Group Products Agent Information Agent Resource Guide Colorado Small Group Underwriting Guides Introducing Lumenos Agent Guide Small Group Bonus Program Brochure EmployerAccess Online Users Manual SMALL GROUP LEGACY PRODUCTS (PLANS A, F, I AND J, HSA 2000 AND HSA 3500) (THESE PLANS ARE NOT ACTIVELY SOLD) Colorado Legacy Group PPO/HSA Enrollment Kit for Employees Pocket folder BluePreferred PPO Plan Overview AFIJ Employee Enrollment App PPO Specialty Products App ( MyHealth@Anthem Overview MBNACESHT- BlueCard Program(PPO only) BluePreferred PPO Plan Overview AFIJ and HSA Qualified Employee Enrollment App PBM-32 NextRX Mail Order Form MBNACESHT- Special Anthem Overview 22 MBNACESHT- MyHealth@Anthem Overview (10/04) BlueCard Program (PPO Only) Colorado Legacy Products Agent Information Product Portfolio Health Savings Account Overview BluePreferred PPO Plan Overview Colorado Small Group Underwriting Guide Booklet ANCILLARY PRODUCTS ALG-9011 CO/NV ALG-9012 CO/NV ProtectionPack ER Brochure (2-9 employees) ProtectionPack ER Brochure (10-50 employees) Anthem EAP Plan Designs and Rates Anthem Life Product Offering Quick Ref Guide O:\Agent Support - ISG\Forms - Miscellaneous\Supply Order Forms\Agent SRF Colorado EXTERNAL USE.doc Revised 07/26/2007 Page 5 of 6

6 499B-PCP PROVIDER DIRECTORIES HMO PCP s and Specialists 106-B PPO Directory of Providers Blue View Vision Provider Directory 988 Anthem Blue Dental PPO Providers 987-CO Anthem Dental PPO Plus Providers HMOSelect Provider Directory To order Medicare Supplement & Part D Materials, please contact Mike Lowry at: MIKE.LOWRY@WELLPOINT.COM or To order a sample certificate, please isgsalessupport@anthem.com. TO ORDER A GROUP ADMINISTRATOR MANUAL, PLEASE SG@ANTHEM.COM OR CALL SMALL GROUP MEMBERSHIP OR TOLL-FREE AT COMMENTS: O:\Agent Support - ISG\Forms - Miscellaneous\Supply Order Forms\Agent SRF Colorado EXTERNAL USE.doc Revised 07/26/2007 Page 6 of 6