Group

• Agreement to protect PHI [pdf]
• Billing adjustment form [pdf]
• Blueprint for Employers registration form [pdf]
• Change request form [pdf]
• COBRA election form [pdf]
• Common ownership certification [pdf]
• Dental claim form [pdf]
• Employee application [pdf]
• Employee application — Spanish version [pdf]
• Enrollment application with medical questionnaire [pdf]
• Enrollment application with medical questionnaire -- Spanish [pdf]
• Health claim form [pdf]
  
• Life employee application [pdf]
• Newborn enrollment request [pdf]
• Physician's incapacity letter [pdf]
• Plan confirmation form [pdf]
• Prescription claim form [pdf]
• Reinstatement application [pdf]
• Subscriber's incapacity form [pdf]
• State of Arkansas Continuation of Coverage election form [pdf]
  
• Vision claim form [pdf]
• Quick Start Guide - ABCBS Group [pdf]
• Quick Start Guide - HA Group [pdf]

2022 Product grids

• Arkansas Blue Cross 2022 Large Group Health Plans - PPO [pdf]
• Arkansas Blue Cross and Health Advantage 2022 Large Group Health Plans - HDHP [pdf]
• Arkansas Blue Cross 2022 Dual Option Health Plans [pdf]
• Arkansas Blue Cross 2022 Small Group Health Plans [pdf]
• Health Advantage 2022 Dual Option Health Plans [pdf]
• Health Advantage 2022 Small Group Health Plans [pdf]
• Health Advantage 2022 Large Group Health Plans-POS [pdf]

2023 Product grids

• Arkansas Blue Cross 2023 Dual Option Health Plans [pdf]
• Arkansas Blue Cross 2023 Small Group Health Plans [pdf]
• Health Advantage 2023 Small Group Health Plans [pdf]

2022 Schedule of Benefits

Platinum

• ABCBS Platinum 1000 Elite [pdf]
• ABCBS Platinum 500 Value [pdf]
• ABCBS Platinum 500 Essential [pdf]
• ABCBS Platinum 500 Elite [pdf]
• ABCBS Platinum 250 Elite [pdf]
• HA Platinum 1000 Elite [pdf]
• HA Platinum 750 Elite [pdf]
• HA Platinum 500 Elite [pdf]
• HA Platinum 250 Elite [pdf]

Gold

• ABCBS Gold 2800 HSA [pdf]
• ABCBS Gold 2500 HSA [pdf]
• ABCBS Gold 2000 Value [pdf]
• ABCBS Gold 2000 Essential [pdf]
• ABCBS Gold 2000 Elite [pdf]
• ABCBS Gold 1500 Value [pdf]
• ABCBS Gold 1500 Essential [pdf]
• ABCBS Gold 1500 Elite [pdf]
• ABCBS Gold 1000 Value [pdf]
• ABCBS Gold 1000 Essential [pdf]
• ABCBS Gold 1000 Elite [pdf]
• HA Gold 2800 HSA [pdf]
• HA Gold 2500 HSA [pdf]
• HA Gold 2000 Value [pdf]
• HA Gold 2000 Elite [pdf]
• HA Gold 1500 Essential [pdf]
• HA Gold 1500 Elite [pdf]
• HA Gold 1000 Essentialm [pdf]

Silver

• ABCBS Silver 8500 HRA [pdf]
• ABCBS Silver 4700 HSA [pdf]
• ABCBS Silver 4500 HSA [pdf]
• ABCBS Silver 4000 Elite [pdf]
• ABCBS Silver 3000 Essential [pdf]
• ABCBS Silver 3000 Elite [pdf]
• ABCBS Silver 2500 Essential [pdf]
• ABCBS Silver 2500 Elite [pdf]
• ABCBS Silver 2000 Essential [pdf]
• ABCBS Silver 2000 Elite [pdf]
• HA Silver 4700 HSA [pdf]
• HA Silver 4250 HSA [pdf]
• HA Silver 3000 Elite [pdf]
• HA Silver 2500 Elite [pdf]
• HA Silver 2000 Essential [pdf]
• HA Silver 2000 Elite [pdf]

Bronze

• ABCBS Bronze 6850 HSA [pdf]
• ABCBS Bronze 6250 Elite [pdf]
• HA Bronze 6850 HSA [pdf]
• HA Bronze 6250 Elite [pdf]