*Note: If employee has a Waiver or Medicare, please indicate W for Waiver Plan (Spouse's Plan or Retiree Plan) or M for Medicare and a Supplement
*Waiver Plans: Coverage can be extended to employees waiving the policyholder’s primary medical plan(s) if they have alternate qualifying primary health coverage, as long as the number of waivers does not exceed 33% of the employees enrolled. Those employees (and their dependent tiers) should be included in the census and SBC for all waiver plan(s) provided. Employees who are only on Medicare will be required to provide evidence of enrollment in Medicare parts A, B and a supplemental plan with Part D.
Questions? Call 1-800-481-3380.