Benefit Summaries & Forms

SuperMed One

1. Standard, Copay
2. Standard, No Copay
3. Short Term
4. HSA 80
5. HSA 100
6. Wellness HSA 80
7. Wellness HSA 100
8. Value
9. Vision
10. Dental

Ohio Farm Bureau

1. Standard 80
2. Standard 90
3. Wellness HSA 80
4. Wellness HSA 100
5. Value
6. High Deductable
7. Vision
8. Dental

Anthem

1. Blue Access
2. Blue Short Term
3. Lumenos HSA
4. Lumenos HIA
5. Lumenos HIA Plus
6. Blue Access Value
7. Blue Access Economy

SuperMed One

• Standard Application
• Short-Term Application

Ohio Farm Bureau

• Standard Application
• OFB New Member Application

Anthem

• Standard Application
• Short-Term Application

MMO Claim Forms

• Major Medical Claim Form
• Prescription Drug Claim Form
• Dental Claim Form
• Vision Claim Form
• Hearing Claim Form

MMO Verification Forms

• Cobra Waiver Approval
• Disability/Overage Dependant Verification Form
• Student Certification Form

Misc Forms

• Underwriting Exception Request
• Medco by Mail Order Form