Documents

To help you better understand your medical plan options, there is an SBC for each plan:

• 2023 Platinum Plan SBC
• 2023 Premium Plan SBC
• 2023 HMSA SBC (Hawaii)
• 2024 Gold Plan SBC
• 2024 Silver Plan SBC
• 2024 HMSA SBC (Hawaii)

Forms

• Beneficiary Designation - Trust, Estate, Charity, or Religious Organization
• VSP Reimbursement
• Maintenance Through Mail Exemption Form
• Maintenance Through Mail Exemption Form for Retail Coupons
• Express Scripts Mail Order Form
• Express Scripts Claim Form
• Anthem Claim Form
• Anthem Continuity of Care Form
• Dependent Care FSA Reimbursement Form
• HSA Custodial Agreement
• 2024 Pay Advance and Wage Deduction Authorization
• Final Wage Trust Form
• Final Wage Spousal Consent Form
• Adoption Assistance Reimbursement Form

Notices

• 2024 Legally Required Notice
• 2024 Affordable Care Act (ACA) Marketplace Notice
• Illinois Essential Health Benefit (EHB) Listing
• 2022 Summary Annual Notice Health & Welfare Program

Tax Information

Edward Jones and its partners provide forms to file your federal taxes.

• Sign up for e-consent and delivery of your 1095 Form.
• Request for Duplicate IRS Form 1095
• Form 1095-C FAQs

Anthem Machine Readable Files (MRFs)

Transparency in Coverage (TIC) regulations require health insurers and group health plans to create MRFs that contain the negotiated rates for in-network providers and allowed amounts derived from historical claims for out-of-network providers and make those files publicly available. A MRF is a digital representation of data or information in a file that can be imported or read by a computer system for further processing without human intervention.

• View the MRFs published monthly by Anthem.