Fillable Renewal And Savings Form - 2016 printable pdf download

2016 Small Employer

Renewal and Savings Form

Blue Solutions

Complete all sections below, sign and date, and return this form by mail, or fax to 215-241-2231, at least 30 days prior to your anniversary date.

Please tyPe or Print clearly

Total number of employees _____________

Contact name _____________________________________________

Title __________________________________________________

Group name ______________________________________________

City ___________________ State ______ ZIP _______________

Federal Tax ID # ______________________

Email address ____________________________________________

Telephone number ______________________________________

Group/CID # _________________________

You will need to choose a new plan from the options listed below. You may contact your IBC account executive for additional information. For your convenience, you will be

automatically enrolled in the recommended coverage if we do not hear from you 30 days prior to your anniversary date.

Please note: Small employer groups may select a maximum of three packaged plans, which include medical, prescription drug, vision (adult and pediatric), and pediatric dental

benefits.

If you currently have more options than what is permitted, you must reduce the number of plans you offer. Based on this requirement, please limit the number of plans

2 3

you offer by selecting the option(s) you would like below and returning this form.

Platinum

gold

silver

bronze

dental

PPO Platinum Preferred $10/$20/$150

PPO Gold Preferred $35/$70/$600

PPO Silver Classic $3,300 $40/$80/100%

DPOS Bronze Essential $6,000 $50/$100/$700

Adult Preventive PPO

PPO Platinum Preferred $20/$40/$150

PPO Gold Classic $1,000 $15/$30/80%

PPO Silver Classic $2,500 $30/$60/80%

HMO Bronze Essential $6,000 $50/$100/$700

Adult Preferred PPO

DPOS Platinum Preferred $10/$20/$100

PPO Gold Classic $2,000 $40/$80/100%

PPO Silver Secure $3,000 $30/$60/$600

PPO Bronze HSA-0 $6,550/100%

Adult Premier PPO with Preventive Incentive

DPOS Platinum Preferred $20/$40/$150

DPOS Gold Classic $1,000 $25/$50/90%

DPOS Silver Classic $2,000 $25/$50/70%

PPO Bronze HSA-0 $4,000/50%

Adult DHMO

HMO Platinum Preferred $10/$20/$100

DPOS Gold Preferred $30/$60/$600

DPOS Silver Classic $4,250 $40/$80/100%

HMO Platinum Preferred $20/$40/$150

DPOS Gold Classic $2,000 $40/$80/100%

DPOS Silver Classic $2,500 $30/$60/50%

PPO Platinum HSA-50 $1,500/100%

HMO Gold Classic $1,000 $25/$50/90%

DPOS Silver Secure $3,500 $40/$80/$600

PPO Platinum HRA-50 $1,500/100%

HMO Gold Preferred $30/$60/$600

HMO Silver Classic $2,000 $25/$50/70%

HMO Gold Classic $2,000 $40/$80/100%

HMO Silver Classic $4,250 $40/$80/100%

HMO Gold Proactive

HMO Silver Classic $2,500 $30/$60/50%

PPO Gold HSA-0 $1,700/100%

HMO Silver Secure $3,500 $40/$80/$600

PPO Gold HSA-25 $2,200/100%

HMO Silver Proactive

PPO Gold HSA-50 $2,200/70%

PPO Silver HSA-0 $2,700/100%

PPO Gold HRA-25 $2,200/100%

PPO Silver HSA-0 $2,400/90%

PPO Gold HRA-50 $2,200/70%

PPO Silver HSA-25 $2,400/50%

PPO Silver HRA-25 $2,400/50%

I would like to offer Blue Solutions Choice.

I would like to add medical coverage for dependents to age 30.

I have employees interested in opening an HSA account with Bank of America

Comments ____________________________________________________________________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________________________________________________________________________________

Employer signature ___________________________________________________________________________________

Effective date ___________________________________________

Upgrades and downgrades are only allowed on the group’s anniversary date.

For groups offering a PPO plan for out-of-area enrollment, the PPO benefit level must be equivalent to the benefit plans offered to the in area employees. Group offerings may not exceed 3 plans, including a plan for out-of-area PPO coverage.

Groups have the option of offering employees up to a maximum of five health plans with Blue Solutions Choice.

2016-1874 7/15 Broker/Direct

All benefit selections must meet Independence Blue Cross underwriting guidelines including number of plan offerings allowed based on group size.

Independence Blue Cross offers products directly, through its subsidiaries Keystone Health Plan East and QCC Insurance Company, and with Highmark Blue Shield, independent licensees of the Blue Cross and Blue Shield Association.

Renewal And Savings Form - 2016

Related Articles

Related forms

Related Categories