Enrollment Forms
FOR NEW ILLINOIS GROUPS IN THE 1-50 MARKET
Employer Application
Employee Enrollment Form
Installation Census
Small Business Participation Form (for groups 10+ eligible)
Tax Documentation
Benefit Selection Form
ACH Form
Authorization Form
FOR NEW ILLINOIS GROUPS IN THE 51-100 MARKET
Employer Application
Employee Enrollment Form with No Medical History
Employee Enrollment Form with Medical History
Fully Insured Member Level Census
HSA OptumHealthBank Enrollment Form
FOR EXISTING ILLINOIS GROUPS WITH NEW EMPLOYEES OR EMPLOYEE STATUS CHANGES
New Hire Employee Enrollment Form
UHC Product Grids
FOR GROUPS IN THE 1-50 MARKET
2021 UHC 1-50 (New Business & Renewals) Illinois Product Package IL025
2021 UHC 1-50 (Renewals Only) Illinois Product Package IL026
2022 UHC 1-50 (New Business) Illinois Product Package IL027
2022 UHC 1-50 (Renewals Only) Illinois Product Package IL028
FOR GROUPS IN THE 51-100 MARKET
2021 IL & NW Indiana – 51+ ATNE; 100 and under Eligible Employees
HOSPITAL/NETWORK LISTING and DESCRIPTION GUIDE
UHC Network Hospital Comparison Grid
UHC Network Description
UHC Fully Insured Plan Description Guide
BROCHURES
2021 IL & NW Indiana Producer Performance Guide
UHC Benefit Services
Packaged Savings
Charter Product Brochure
Charter Product FAQ
Nexus ACO Product Brochure
Specialty Benefits Quick Reference Guide
Ubundle vs Packaged Savings
Benefitter Brochure
CLAIM FORMS
Medical Claim Form
UHC Dental Claim Form
RX Claim Form
Benefit Summaries
AH-A2
AH-A3
AH-A4
AH-A5
AH-A6
AH-A7
AH-A8
AH-A9
AH-AA
AH-AB
AH-AC
AH-AD
AH-AE
AH-AF
AH-AG
AH-AH
AH-AI
AH-AJ
AH-AK
AH-AL
AH-AM
AH-AN
AH-AO
AH-AP
AH-AQ
AH-AR
AH-AS
AH-AT
AH-AU
AH-AV
AH-AW
AH-AX
AH-AY
AH-AZ
AH-B1
AH-B2
AH-B3
AH-B4
AH-B5
AH-B6
AH-B7
AH-B8
AH-B9
AH-BA
AH-BB
AH-BC
AH-BD
AH-BE
AH-BF
AH-BG
AH-BH
AH-BI
AH-BJ
AH-BK
AH-BL
AH-BM
AH-BN
AH-BO
AH-BP
AH-BQ
AH-BR
AH-BS
AH-BT
AH-BU
AH-BV
AH-BW
AH-BX
AH-BY
AH-BZ
AH-CA
AH-CB
AH-CC
AH-CD
AH-CE
AH-CF
AH-CG
AH-CH
AH-CI
AH-CJ
AH-CK
AH-CL
AH-CM
BD-AO
BD-AP
BD-AQ
BD-AR
BD-AS
BD-AT
BD-AU
BD-AV
BD-AW
BD-C2
BD-C3
BD-C4
BD-C5
BD-C6
BD-C7
BD-C8
BD-C9
BD-CX
BD-CY
BD-CZ
BD-DA
BD-DI
BD-DJ
BD-DK
BD-DL
BD-DM
BD-DN
BD-DO
BD-DP
BD-P2
BD-P3
BD-P4
BD-P5
BD-P6
BD-P7
BD-P8
BD-P9
BD-PY
BD-PZ
BD-Q2
BD-Q3
BD-QA
BD-QB
BD-QC
BD-QD
BD-QE
BD-QF
BD-QG
BD-QH
BD-QI
BD-QJ
BD-QK
BD-QL
BD-QM
BD-QN
BD-QO
BD-QP
BD-QQ
BD-QR
BD-QS
BD-QT
BD-QU
BD-QV
BD-QW
BD-QX
BD-QY
BD-QZ
BD-R2
BD-R3
BD-R4
BD-R5
BD-R6
BD-R7
BD-R8
BD-R9
BD-RQ
BD-RR
BD-RS
BD-RT
BD-RU
BD-RV
BD-RW
BD-RX
BD-RY
BD-RZ
BD-S2
BD-S3
BD-S4
BD-S5
BD-S6
BD-S7
BD-S8
BD-S9
BD-SA
BD-SB
BD-SC
BD-SD
BD-SE
BD-SF
BD-SG
BD-SH
BD-SI
BD-SJ
BD-SK
BD-SL
BD-SM
BD-SN
BD-SO
BD-SP
BD-SQ
BD-SR
BD-SS
BD-ST
BD-SU
BD-SV
BD-SW
BD-SX
BD-SY
BD-SZ
BD-T2
BD-T3
BD-T4
BD-T5
BD-TA
BD-TB
BD-TC
BD-TD
BD-TE
BD-TF
BD-TG
BD-TH
BD-TI
BD-TJ
BD-TK
BD-TL
BD-TM
BD-TN
BD-TO
BD-TP
BD-TQ
BD-TR
BD-TS
BD-TT
BD-TU
BD-TV
BD-TW
BD-TX
BD-TY
BD-TZ
BF-C3
BF-C4
BF-C5
BF-C6
BF-C7
BF-C8
BF-C9
BF-CT
BF-CU
BF-CV
BF-CW
BF-CX
BF-CY
BF-CZ
BF-D2
BF-D3
BF-D4
BF-D5
BF-D6
BF-D7
BF-D8
BF-D9
BF-DA
BF-DB
BF-DC
BF-DD
BF-DE
BF-DF
BF-DG
BF-DH
BF-DI
BF-DJ
BF-DK
BF-DL
BF-DM
BF-DN
BF-DO
BF-DP
BF-DQ
BF-DR
BF-DS
BF-DT
BF-DU
BF-DV
BF-DW
BF-DX
BF-DY
BF-DZ
BF-EA
BF-EB
BF-EC
BF-ED
BF-EE
BR-N7
BR-N8
BR-N9
BR-O2
BR-O3
BR-O4
BR-O5
BR-O6
BR-O7
BR-O8
BR-O9
BR-OA
BR-OB
BR-OC
BR-OD
BR-OE
BR-OF
BR-OG
BR-OH
BR-OI
BR-OJ
BR-OK
BR-OL
BR-OM
BR-ON
BR-OO
BR-OP
BR-OQ
BR-OR
BR-OS
BR-OT
BR-OU
BR-OV
BR-OW
BR-OX
BR-OY
BR-OZ
BR-PA
BR-PB
BR-PC
BR-PD
BR-PE
BR-PF
BR-PG
BR-PH
BR-PI
BR-PJ
BR-PK
BR-PL
BR-PM
BR-PN
BR-PO
BR-YG
BR-YH
BR-YI
BR-YJ
BR-YK
BR-YL
BR-YM
BR-YN
BR-YO
BR-YP
BR-YQ
BR-YR
BR-YS
CC-N3
CC-N4
CC-N5
CC-N6
CC-N7
CC-N8
CC-N9
CC-NO
CC-NP
CC-NQ
CC-NR
CC-NS
CC-NT
CC-NU
CC-NV
CC-NW
CC-NX
CC-NY
CC-NZ
CC-O2
CC-O3
CC-O4
CC-O5
CC-O6
CC-O7
CC-O8
CC-O9
CC-OA
CC-OB
CC-OG
CC-OH
CC-OI
CC-OJ
CC-OK
CC-OL
CC-OM
CC-OO
CC-OP
CC-OQ
CC-OR
CC-OS
CC-OT
CC-OU
CC-OV
CC-OW
CC-OX
CC-OY
CC-OZ
CC-P2
CC-P3
CC-P4
CC-P5
CC-P6
CC-P7
CC-P8
CC-P9
CC-PA
CC-PB
CC-PC
CC-PD
CC-PE
CC-PF
CC-PG
CC-PH
CC-PI
CC-PJ
CC-PL
CC-PK
CC-PM
CC-PN
CC-PO
CC-PP
CC-PQ
CC-PR
CC-PS
CC-PT
CC-PU
CC-PV
CC-PW
CC-PX
CC-PY
CC-PZ
CC-QA
CC-QB
CC-QC
CC-QD
CC-QE
CC-QF
CC-QG
CC-QH
CC-QI
CC-QJ
2021 Access Preferred Drug Listing (3 Tier)
2022 Access Preferred Drug Listing (3 Tier)
2021 Access Preferred Drug Listing (4 Tier)
2022 Access Preferred Drug Listing (4 Tier)
2021 Advantage Preferred Drug Listing (3 Tier)
2022 Advantage Preferred Drug Listing (3 Tier)
2021 Advantage Preferred Drug Listing (4 Tier)
2022 Advantage Preferred Drug Listing (4 Tier)
2021 Essential Drug Listing (4 Tier)
2022 Essential Drug Listing (4 Tier)
Access vs Advantage PDL
Essential PDL Brochure
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2V HSA
3B
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EU
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