Benefit Summaries & Forms

SuperMed One

1. 1200 HSA Plan
2. 1200 Wellness HSA
3. 2500, 3000, 5000 Wellness HSA
4. 2500, 3000, and 5000 HSA Plans
5. 2500, 5000, and 10,000 Standard, No Copay
6. 500, 1000, 1500, and 2500 Standard, Copay
7. Dental Plan
8. Short Term Plans
9. Value Plan
10. Vision Plan

Ohio Farm Bureau

1. 1200 and 2400 Wellness HSA Plans
2. 1750, 2500, 3500, 5000 Wellness HSA Plans
3. 2000 and 4000 High Deductible Plans
4. 750 and 1500 90% Standard Plans
5. 750, 1500, 2500 80% Standard Plans
6. Dental Benefits
7. Value Plans
8. Vision EyeMed Access Network

Anthem

1. Lumenos Health Incentive Account (HIA) Plan 1
2. Lumenos Health Incentive Account (HIA) Plan 2
3. Lumenos Health Incentive Account Plus (HIA) Plan 1
4. Lumenos Health Incentive Account Plus (HIA) Plan 2
5. Lumenos Health Savings Account (HSA) Plan 1
6. Lumenos Health Savings Account (HSA) Plan 2
7. Premier 0% Coinsurance Option
8. Premier 20% Coinsurance Option
9. SmartSense

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