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Forms
Agent Change Request (Fillable PDF)
- Change the agent of record for a health coverage plan
Application for Individual Coverage (PDF)
Application for Individual Coverage (Spanish) / Solicitud de Cobertura Individual (PDF)
Pre-Sale Disclosure List for Individual Plan Members (PDF)
Newborn Application (PDF)
Electronic Funds Transfer (PDF)
Creditable Coverage FAQs for Agents (PDF)
Creditable Coverage Status for Facets Pharmacy Products (PDF)
Regence Breakthru
SM
Regence Breakthru
SM
70, $1,000/$3,000
Summary of Benefits - English (PDF)
Prescription Summary of Benefits - English (PDF)
Exclusions (PDF)
Regence Breakthru
SM
50, $2,500/$5,000
Summary of Benefits - English (PDF)
Exclusions (PDF)
Regence Breakthru
SM
80
Summary of Benefits (PDF)
Prescription Summary (PDF)
Regence NowSelect
SM
Summary of Benefits - English (PDF)
Exclusions (PDF)
Regence HSA Healthplans
Regence HSA Healthplan
Summary of Benefits (PDF)
Exclusions (PDF)
Regence HSA Comprehensive Healthplan
Summary of Benefits (PDF)
Prescription Summary (PDF)
Exclusions (PDF)
DentalOne
Application (PDF)
Brochure (PDF)
Rates (PDF)
Older Plans
Rates
Closed Individual rates (all plans) (PDF)
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