Marketing Materials Order Form
 
     
 Instructions
  1. Indicate the materials you want to order by completing the “quantity” field. You can search by form name or number by using Ctrl + F.
  2. Proceed to the bottom of the form to enter the required information in the fields below.

    If you experience problems with this form, or have questions about your order, please send an e-mail message to PRODSPT@nebraskablue.com.
     
 
Envelopes
Form NumberForm NameQuantity
70510 x 13 Envelope with Important Plan Information message - must be used when mailing Medicare PPO or Rx materials to prospects and beneficiaries
523310 x 13 Envelope with BlueSenior Classic Medicare Supplement plan info on front - not for mailing of Medicare PPO or Rx materials/kits
1898Postage-paid return envelope - Individual Underwriting Department (9 x 4)
1899Postage-paid return envelope - Individual Underwriting Department (6 x 9)
1901Postage-paid return envelope - Individual Underwriting Department (13 x 10)
 
     
 
Miscellaneous
Form NumberForm NameQuantity
N-11-183 (English)BlueCard Program (for members to locate providers throughout the U.S.)
N-11-183 (Spanish)BlueCard Program (Spanish version for members to locate providers throughout the U.S.)
N-11-187BlueCard Worldwide Program (for members to locate providers around the world)
42-046Summary of Benefits and Coverage postcard
89832-pocket folder: Health Plans for Individuals Under age 65
8909Generic BCBSNE 2-pocket folder
89752-pocket Medicare Supplement folder
4961One Less Thing to Worry About Flyer
92-096High Deductible Health Plans and HSAs - Group (7-31-12 version for 2013)
92-096High Deductible Health Plans and HSAs - Group (8-7-13 version for 2014)
9017Conversion Coverage Health Care Plan
42-013Open Look under age 65 individual plan performance brochure
92-140Consumer Guide to the New Health Care Law
92-141Health Care Reform Small Business Guide
36-027Your Guide to Health Care Reform-for brokers and employer-group clients
36-182Health Care Reform: New Benefits, New Costs-for brokers and employer-group clients
36-051Benefits for Preventive Services (for grandfathered plans or plans that have not reached their first plan year on or after plan years beginning 8-1-12)
36-051-3Benefits for Preventive Services (for plan years beginning on or after 5-1-14)
36-165Three-Tier Plan Design Frequently Asked Questions
36-100Online Tools and Resources from BCBSNE
4975In-Network Providers Card
 
     
 
 Applications
IMPORTANT NOTE: Beginning June 1, 2011, a $25 broker fee will be charged for every paper application submitted.
Form NumberForm NameQuantity
3087 rev 10-7-13Application for Individual Coverage (use for 2014 ACA-compliant plans or to add DentalEssentials to any health plan)
3179Major Medical Special Mail Application (use for non-underwritten coverage changes only; medical underwriting is required if the new coverage has a lower deductible/coinsurance and/or richer benefits)
3062TempCare Application and Contract
31-095DentalEssentials stand-alone application
3041Medicare Supplement with optional DentalEssentials application
 
     
 
Directories
Form NumberForm NameQuantity
36-066NEtwork BLUE Directory
 
     
 
 Forms
Form NumberForm NameQuantity
Y0052Medicare Scope of Appointment Form
4964Sales and marketing event notification form
31-076TempCare coverage disclaimer
36-002Application reporting form
8664-4Authorization for Release of Protected Health Information
5925Cancellation request
3632Carve out form (pending application) (also known as a Bank Depositor Form – use when additional information is needed before an application/change can be processed)
3117Certification of Non-Applicability of the Health Insurance Portability And Accountability Act (HIPAA)
8682Consumer Insurance Disclosure
3228Dependency Statement (use to certify and list eligible dependents)
1859Effective Date Form (for new customers only; not transfers between BCBSNE plans/products)
8886Important Information about the Automatic Withdrawal of Your BCBSNE Monthly Premium
3253Medicare Card Form (requests Medicare number and A and B effective dates)
6112Membership Change Request (add newborn, dependent, student information)
3085Non-Tobacco User Certification
3205Notice to Applicant Regarding Replacement of Medicare Supplement Insurance or Medicare Advantage
PRI-2296Patient Medication List Drug Formulary (Prime Therapeutics)
1896Preferred premium discount medical questionnaire
3640Reinstatement request
9071Rx Nebraska Prescription Drug Benefits
6177Subscriber’s claim form
 
     
 
 MedicareBlue Rx Products
Available to Medicare-Certified Agents & Brokers Only
 
BCBSNE will not send the following MedicareBlue PPO and/or MedicareBlue Rx marketing materials to agents who are not certified to sell Medicare products. Please check the box below to verify you have completed both the AHIP training and the product training to become Medicare certified.

I verify that I am currently certified to sell MedicareBlue products. I understand that selling MedicareBlue products without being certified can result in loss of my sales appointment.
 
Form NumberForm NameQuantity
RAS 1001R062014 MedicareBlue Rx pre-enrollment kit (includes formulary and sell sheet)
 
     
 
 Individual DentalEssentials
Form NumberForm NameQuantity
36-141DentalEssentials individual dental brochure
 
     
 
 2014 Individual Benefits Brochures
Form NumberForm NameQuantity
92-133BlueEssentials Plus and Select Blue Plus benefits brochure (metro area)
92-134BlueEssentials Plus benefits brochure (outside of metro area)
92-139BlueEssentials Plus $6350 Catastrophic plan option benefits brochure
 
     
 
 Product Brochures -- Under Age 65 Plans
Form NumberForm NameQuantity
92-069TempCare (temporary plans) benefits brochure
 
     
 
 Product Brochures -- Over Age 65 Plans
Form NumberForm NameQuantity
9135 rev. 12-24-12BlueSenior Classic Medicare Supplement customer brochure. Use when selling 2013 plans
9135 rev. 11-1-13BlueSenior Classic Medicare Supplement customer brochure. Use when selling 2014 plans
CMS Pub. 02110Choosing a Medigap Policy: A Guide to Health Insurance for People with Medicare (CMS publication for use with Med Supp sales)
36-013Plan L promotional flyer
RAS1005R062014 How Medicare Works booklet
 
     
 
 Rate Books
Form NumberForm NameQuantity
36-1912014 Individual Monthly Plan Rates book - On and Off Exchange Plans
36-2102014 Individual Non-ACA Monthly Plan Rates book - No Longer Available for New Sales
36-2112014 TempCare Rate Sheet
 
     
 
 Outlines of Coverage
Form NumberForm NameQuantity
92-126SelectBlue individual three-tier Outline of Coverage
9175 rev. 12-20-13BlueSenior Classic Medicare Supplement Plans. Use when selling 2014 plans
 
     
 
 Manuals
Form NumberForm NameQuantity
4962 PRINTGroup Administration Manual (for groups under our New Claims and Membership System)
4962 CDGroup Administration Manual (for groups under our New Claims and Membership System)
 
     
 
 PremierBlue (health plans for employer groups with 100+ eligible employees)
Form NumberForm NameQuantity
92-106PremierBlue Brochure
 
     
 
 BlueFreedom (health plans for employer groups of 51-99 employees)
Form NumberForm NameQuantity
8904BlueFreedom Benefits Brochure (for groups effective on and after 8-1-12)
8906BlueFreedom Benefits Options at a Glance (for groups effective on and after 8-1-12)
36-195BlueFreedom plan options brochure (2014 effective dates)
 
     
 
 BluePride (health plans for employer groups of 2-50 employees)
Form NumberForm NameQuantity
4727BluePride benefits brochure (for groups effective on and after 1-1-13)
4728BluePride Options at a Glance (for groups effective on and after 1-1-13)
30-009-06BluePride Master Group Application
31-046BluePride Employee Enrollment Form (for 2013 plan year groups)
31-046-01BluePride Plus Employee Enrollment Form (for 2014 plan year groups)
36-093Fremont BlueChoice Brochure/Options at a Glance
36-128Fremont BlueChoice How to search for Fremont BlueChoice providers
36-186BluePride Plus plan options brochure (2014 effective dates)
 
     
 
 Group Three-Tier Health Plan Options
Form NumberForm NameQuantity
36-147Small Group Three-Tier Plan Options – for brokers/group leaders (effective 1/1/13 and after for groups of 2-99)
36-165Member FAQs (effective 1/1/13 and after for ASO groups of 2-99 who cross accumulate)
36-180SelectBlue Large Group Three-Tier Plan Options – for brokers/group leaders (effective 1/1/14 for employer groups of 100+)
36-177How to Use the Online Provider Directory – for members (effective 1/1/14 for employer groups of 2+)
36-181Member FAQs (effective 1/1/14 for employer groups of 2+ who do not cross accumulate)
36-185SelectBlue Plus Plan Options brochure (2014 effective dates for groups of 2-50)
 
     
 
 SignatureBlue (dental plans for employer groups of 2+)
Form NumberForm NameQuantity
36-029SignatureBlue Dental Brochure
 
     
 
 Group and Voluntary Life, AD&D, and Disability (for employer groups of 2+)
Form NumberForm NameQuantity
ABOUTUS-NE-BRKRMeet USAble Life Broker Brochure
USAL-VGTL-BRVoluntary Term Life Brochure
USAL-GTL-BRGroup Term Life Brochure
USAL-VADD-BRVoluntary Accidental Death and Dismemberment Brochure
USAL-VSTD-BRVoluntary Short Term Disability Brochure
USAL-GSTD-BRGroup Short Term Disability Brochure
USAL-VLTD-BRVoluntary Long Term Disability Brochure
USAL-GLTD-BRGroup Long Term Disability Brochure
USAL-SGG2-NEProviding More Benefits for Less (Small Group Bundled Product – 2-50 Employees)
 
     
 
 Group Vision (for employer groups of 2+)
Form NumberForm NameQuantity
-Standard Group Products (2-49 employees)
-Standard Group Products (50+ employees)
BCBSNE082012 Plan Options
 
     
 
 Discount Programs
Form NumberForm NameQuantity
36-050Blue365 discount program flier for all audiences
36-117Individual hearing and vision discount programs flyer
 
     
 
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Date: 4/17/2014
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