ISMA Health Insurance Forms and Information

 

Included on this page are links to various ISMA health insurance forms, brochures, and other information.

 

Just click on the circular icons next to each topic for a brief summary, as well as access to view, save and/or print the forms in pdf format. (Please note that the linked files are accessed by clicking on the blue text.)

 

If you don’t see what you’re looking for here, please email Tom Martens at the ISMA.

Administrative Policies

Administrative Policies

Administrative procedures for enrolling new employees, changing policies, terminating policies, eligibility, COBRA, HIPAA, premium billing, etc. to keep your plan running smoothly.

Anthem Dental Claim Form

Anthem Dental Claim Form

Use this form to file a dental claim with Anthem if you have the optional Dental plan and your dentist’s office will not file a claim for you.

Anthem Designation of Authorized Representative Forms

Anthem Designation of Authorized Representative Forms

Use this form to authorize a person to have access to your personal claims information, such as an adult child.

Anthem Domestic Partner Affidavit

Anthem Domestic Partner Affidavit

Use an Anthem Enrollment Application and this form to request coverage for your domestic partner.

Anthem Employer Application for Groups

Anthem Employer Application for Groups

Anthem Employer Application for Groups

Anthem Enrollment Application for Groups

Anthem Enrollment Application for Groups

Physicians and Employees in Groups insured with ISMA/Anthem use this form to apply for new policies or to request changes to existing policies.

Anthem Enrollment Application for Individuals

Anthem Enrollment Application for Individuals

Physicians and Employees insured with ISMA/Anthem as individuals use this form to apply for new policies or to request changes to existing policies.

Anthem Medical Claim Form

Anthem Medical Claim Form

Use this form to file a medical claim with Anthem if your provider’s office will not file a claim for you.

Anthem Worldwide Coverage Brochure

Anthem Worldwide Coverage Brochure

Did you know your ISMA/Anthem policy provides benefits worldwide? Find more information in this helpful brochure.

ExpressScripts New Patient Order Form

ExpressScripts New Patient Order Form

Use this form if your ISMA/Anthem includes a 90-day prescription drug mail order option to place an order for a new prescription.

ExpressScripts Mail Order Form

ExpressScripts Mail Order Form

Use this form to have prescriptions mailed to your home.

Express Scripts Prescription Drug Claim Form

Express Scripts Prescription Drug Claim Form

Use this form to file a claim for a prescription you already purchased.

FAQ Regarding Attaining Age 65

FAQ Regarding Attaining Age 65

Provides information about what you need to do before you attain age 65 and start Medicare.

Instructions for Requesting Changes to Anthem (GROUP) Policies

Instructions for Requesting Changes to Anthem (GROUP) Policies

Instructions for requesting changes to an ISMA/Anthem policy, including adding or deleting dependents, requesting a plan upgrade, requesting a review of risk class, changing a name, or changing a life insurance beneficiary.

Instructions for Requesting Changes to Anthem (INDIVIDUAL) Policies

Instructions for Requesting Changes to Anthem (INDIVIDUAL) Policies

Instructions for requesting changes to ISMA/Anthem policy, including adding or deleting dependents, requesting a plan upgrade, requesting a review or risk class, changing a name, or changing a life insurance beneficiary.

ISMA/Anthem Health Insurance Brochure

ISMA/Anthem Health Insurance Brochure
2017 – 2018

Describes the unique advantages of the ISMA/Anthem group medical, life and dental insurance program and describes plans and benefits.

ISMA Medicare Carve-Out Brochure

ISMA Medicare Carve-Out Brochure

Describes the ISMA/Medicare Carve-Out Policy, which serves as a supplement to Medicare.

 

Medicare Carve-Out Summary with Rates

Medicare Carve-Out Summary with Rates

Provides a short summary of the ISMA/Anthem Medicare Carve-Out Policy; which serves as a supplement to Medicare, including rates.

 

Premiums ACH Authorization Form

Premiums ACH Authorization Form

Complete and submit this form to authorize automatic payment of ISMA health insurance premiums directly from your checking account.

Instructions on Joining the ACH Direct Payment Plan

ACH Authorization Form Instructions

Step by step instructions on how to sign up for the Direct Payment Via ACH Plan

HIPAA Authorization Form

HIPAA Authorization Form

Authorization for your insurance company to release your medical records to the ISMA or other entity.