Anthem Small Group Supply Request Form

For producers and group administrators ordering group forms

Please use this form to order printed supplies of the materials listed below.

To request a faxed or e-mailed copy of a form, contact your producer support representative.

Because our materials are revised often, please order no more than a 30-day supply.

Send completed form: Fax: 314-923-6852 or 1-888-800-1068

E-mail:

Form Title

/

Form Number

/ Quantity
Employer Application / AMOWI-100
Employee Application / AMO-216
Employee Change Form / AMO-83
Life - Employee Application / A-MWL-E
Blue 3.1 Blue Access PPO Overview / ERMOWISHT-41
Blue 3.1 Blue Access Choice PPO Overview / ERMOSHT-42
Blue 3.1 Blue Access Hospital/Surgical PPO Overview / ERMOSHT-43
Blue 3.1 Blue Preferred Plus POS Overview / ERMOSHT-38
Blue 3.1 Blue Preferred HMO Overview / ERMOWISHT-40
Spectrum of Services / ERMOFLD-36
Anthem Life –Statement of Death Group Claim Form / AL-8000
Group Administration Manual / EMMOWIBRO-195
My Anthem for Employers brochure / ERCEBRO-163
My Anthem for Brokers Overview / BRCEBRO-24
Lumenos General Sales Brochure for group proposals / ERCEBRO-223
Lumenos At-a-Glance Overviews for proposals (specify HIA, HRA, HSA Gift Card or HSA without incentives)
Lumenos Introductory HRA Consumer Brochure / EMCEBRO-225
Lumenos Introductory HIA Consumer Brochure / EMCEBRO-226
Lumenos Introductory HSA with Gift Card Consumer Brochure / EMCEBRO-358
Lumenos HSA without Incentives Introductory Educational Brochure / EMCEBRO-259
Lumenos Plan Summaries for enrollment kits (specify HIA, HRA, HSA Gift Card or HSA without incentives)
Mellon Bank HSA Consumer Overview
Anthem’s Prescription Drug Plan – Drug List / MBCEBRO-10
Anthem’s Prescription Drug Program – Tiered Drug List / MBCEBRO-11
DentaBlue Employer Slick / ERMOSHT-56
Other
Other

Requestor Name ______

Requestor Phone number ______

Agency or Company name ______

Requestor’s street address ______

City ______State ______ZIP Code ______

In most of Missouri, Anthem Blue Cross and Blue Shield is the trade name of RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC) and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc.Life and disability productsare underwritten by Anthem Life Insurance Company (ALIC). RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.