Documents & Forms Center

2017 Essential Selection No Rx

PDF icon SBC - 2017 Essential Selection No Rx.pdf

2018 3101 - Platinum 153050 - Religious Exemption

PDF icon SBC - 2018 3101 - Platinum 153050 - Religious Exemption.pdf

Agents

2018 3104 - Gold 1550100

PDF icon SBC 2018 3104 - Gold 1550100.pdf

Medicare

2018 Advantage Plus Annual Notice of Changes

PDF icon 2018 Advantage Plus Annual Notice of Changes.pdf

Medicare

2018 Advantage Plus Evidence of Coverage

PDF icon 2018 Advantage Plus Evidence of Coverage.pdf

Medicare

2018 Advantage Plus Preferred Advantage Enrollment Application

PDF icon 2018 Advantage Plus Preferred Advantage Enrollment Application.pdf

Medicare

2018 APPA Enrollment Checklist 012618

PDF icon 2018 APPA Enrollment Checklist 012618.pdf

Medicare

2018 APPA Summary of Benefits

PDF icon 2018 APPA Summary of Benefits.pdf

Medicare

2018 Big Bend Choice Retiree Advantage (HMO) Schedule of Copayments

PDF icon 2018 Big Bend Choice Retiree Advantage (HMO) Schedule of Copayments.pdf

Medicare

2018 Capital Health Plan Advantage Plus Preferred Advantage Summary of Benefits

PDF icon 2018 Capital Health Plan Advantage Plus Preferred Advantage Summary of Benefits.pdf

Members

2018 Capital Health Plan Summary of Benefits

PDF icon 2018 Capital Health Plan Summary of Benefits.pdf

Medicare

2018 Capital Selection 15 30 50 Retiree Advantage (HMO) Schedule of Copayments

PDF icon 2018 Capital Selection 15 30 50 Retiree Advantage (HMO) Schedule of Copayments.pdf

Medicare

2018 Capital Selection 15 50 100 Retiree Advantage (HMO) Schedule of Copayments

PDF icon 2018 Capital Selection 15 50 100 Retiree Advantage (HMO) Schedule of Copayments.pdf

Providers

2018 COM Criteria - Applied Behavioral Analysis Services

PDF icon 2018 COM Criteria - Applied Behavioral Analysis Services.pdf

Providers

2018 COM Criteria - Colonoscopies

PDF icon 2018 COM Criteria - Colonoscopies.pdf

Providers

2018 COM Criteria - Long Term Acute Care Hospitalization

PDF icon 2018 COM Criteria - Long Term Acute Care Hospitalization.pdf

Providers

2018 COM Criteria - Magnetic Resonance Imaging (MRI) Cervical Spine

PDF icon 2018 COM Criteria - Magnetic Resonance Imaging (MRI) Cervical Spine.pdf

Providers

2018 COM Criteria - Magnetic Resonance Imaging (MRI) Lumbar Spine

PDF icon 2018 COM Criteria - Magnetic Resonance Imaging (MRI) Lumbar Spine.pdf

Providers

2018 COM Criteria - Residental Substance Abuse Treatment

PDF icon 2018 COM Criteria - Residental Substance Abuse Treatment.pdf

Providers

2018 COM Criteria - Residential Eating Disorders Treatment

PDF icon 2018 COM Criteria - Residential Eating Disorders Treatment.pdf

Providers

2018 COM Criteria - Skilled Nursing Facilities

PDF icon 2018 COM Criteria - Skilled Nursing Facilities.pdf

Providers

2018 COM Criteria - Sleep Studies

PDF icon 2018 COM Criteria - Sleep Studies.pdf

Providers

2018 COM Criteria - Thoracic Outlet Syndrome

PDF icon 2018 COM Criteria - Thoracic Outlet Syndrome_0.pdf

Providers

2018 COM Criteria - TMH Bariatric Center

PDF icon 2018 COM Criteria - TMH Bariatric Center.pdf