Documents

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

• 2022 Platinum Plan SBC
• 2022 Premium Plan SBC
• 2022 HMSA SBC (Hawaii)
• 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
• 2023 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.

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.