Member Services: 1-800-838-8271 TTY: 711

To enroll by phone call: 1-800-838-5914

Benefits

Imperial Insurance Company Traditional (HMO) 003

English

  • ANOC 003 – [PDF, 499KB]
  • Evidence of Coverage 003 – [PDF, 4MB]
  • Summary of Benefits – [PDF, 1MB]
  • Summary of Benefits Errata – [PDF, 24KB]
  • Dental Benefits – [PDF, 481KB]
  • Enrollment Kit – [PDF, 3MB]

Spanish

  • ANOC 003 – [PDF, 499KB]
  • Evidence of Coverage 003 – [PDF, 4MB]
  • Summary of Benefits – [PDF, 1MB]
  • Summary of Benefits Errata – [PDF, 24KB]

2020 Over-the-Counter Benefit and Order Form

  • 2020 Over-the-Counter Benefit and Order Form
  • 2020 Over-the-Counter (OTC) Benefit and Order Form – English [PDF, 281KB]
  • 2020 Over-the-Counter (OTC) Benefit and Order Form – Spanish [PDF, 310KB]
  • 2020 Over-the-Counter (OTC) Benefit and Order Form – Chinese [PDF, 356KB]

Imperial Insurance Company Dual (HMO D-SNP) 004

English

  • ANOC 003 – [PDF, 499KB]
  • Evidence of Coverage 003 – [PDF, 4MB]
  • Summary of Benefits – [PDF, 1MB]
  • Summary of Benefits Errata – [PDF, 24KB]
  • Dental Benefits – [PDF, 481KB]
  • Enrollment Kit – [PDF, 3MB]

Spanish

  • ANOC 003 – [PDF, 499KB]
  • Evidence of Coverage 003 – [PDF, 4MB]
  • Summary of Benefits – [PDF, 1MB]
  • Summary of Benefits Errata – [PDF, 24KB]

2020 Over-the-Counter Benefit and Order Form

  • 2020 Over-the-Counter Benefit and Order Form
  • 2020 Over-the-Counter (OTC) Benefit and Order Form – English [PDF, 281KB]
  • 2020 Over-the-Counter (OTC) Benefit and Order Form – Spanish [PDF, 310KB]
  • 2020 Over-the-Counter (OTC) Benefit and Order Form – Chinese [PDF, 356KB]

Imperial Insurance Value (HMO C-SNP) 005

English

  • ANOC 003 – [PDF, 499KB]
  • Evidence of Coverage 003 – [PDF, 4MB]
  • Summary of Benefits – [PDF, 1MB]
  • Summary of Benefits Errata – [PDF, 24KB]
  • Dental Benefits – [PDF, 481KB]
  • Enrollment Kit – [PDF, 3MB]

Spanish

  • ANOC 003 – [PDF, 499KB]
  • Evidence of Coverage 003 – [PDF, 4MB]
  • Summary of Benefits – [PDF, 1MB]
  • Summary of Benefits Errata – [PDF, 24KB]

2020 Over-the-Counter Benefit and Order Form

  • 2020 Over-the-Counter Benefit and Order Form
  • 2020 Over-the-Counter (OTC) Benefit and Order Form – English [PDF, 281KB]
  • 2020 Over-the-Counter (OTC) Benefit and Order Form – Spanish [PDF, 310KB]
  • 2020 Over-the-Counter (OTC) Benefit and Order Form – Chinese [PDF, 356KB]

To read PDFs, you will need Adobe Acrobat Reader. You can download here.

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