Preferred Maketing Associates (PMA)
Monday - Thursday:
8 am - 4:45 pm
Friday:
8 am - 12:30 pm
Supplies
            2017 Individual Health Application  (220 kb)
      Changes to the plans cannot be made. This app is for adding/removing dependents.
            Applicaton for Pre-ACA Changes  (152 kb)
            2017 Individual Rate Book  (194 kb)
      Zip codes 680-681
            2017 SelectBlue Product Brochure  (2013 kb)
      Zip codes 683-685
            2017 SelectBlue and BlueEssentials Product Brochure  (11640 kb)
      Zip codes 686-693
            2017 BlueEssentials Product Brochure  (16981 kb)
            2017 Agent Admin Guide and SEP Guide  (597 kb)
            2017 Formulary  (2906 kb)
            Extension of Coverage to Age 30 form  (24 kb)
            Extension of Coverage for Disable Dependents form  (44 kb)
      Form 3117 is to be completed when an business account is being used to pay the premium.
            HIPAA Form  (25 kb)
            Cancellation Form  (74 kb)
            PHI Release Form  (145 kb)
      Request for Premium Rate Reduction Due to Change in Health Status or Tobacco Cessation Medical Questionnaire
            Premium Rate Reduction Tobacco Questionnaire (Non-ACA plans)  (76 kb)
      Request for Premium Rate Reduction Due to Change in Health Status or Tobacco Cessation Medical Questionnaire
            Premium Rate Reduction Tobacco Questionnaire (ACA plans)   (42 kb)
            Reinstatement Request Form  (149 kb)
            HSA Account Information Request Form  (58 kb)
            Preventive Care Guidelines  (285 kb)
            Benefits for Preventive Services  (361 kb)
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