All of the forms listed below are in PDF format which allows you to view them
electronically on most computers. The Adobe Acrobat reader is required to view
and print PDF files. If you do not have the reader,
click here to download free
- Click Here for free online quotes, to compare plan rate prices and benefits side-by-side, and apply for ACHIA insurance online.
- Click Here for fillable application. Email completed application to firstname.lastname@example.org.
* Please note that all Eligibility requirements must be met and the policy has Pre-Existing Condition Limitation
Pre-Existing Condition Limitation: The policy will not cover expenses incurred during the first 6 months after its effective date for a preexisting condition. The plan will pay only for expenses incurred after such 6-month period. However, if you had coverage under another medical plan or policy ("prior plan") which was involuntarily terminated and you apply for coverage under this policy within 31 days after such involuntary termination from coverage under the "prior plan", the limitation to a preexisting condition will apply only for a period of time equal to 6 months less the time you were covered under the "prior plan".
- Alaska Brochure
- Authorization Agreement For Preauthorized Payments
- Authorization for Release of Protected Health Information Form
Schedule of Benefits
- CARVEOUT PLAN - $1,000 Deductible, $2,500 Out-of-Pocket Maximum
- PLAN A-$1,000 Deductible, $2,500 Out-of-Pocket Maximum
- PLAN B-$1,500 Deductible, $3,000 Out-of-Pocket Maximum
- PLAN C-$2,500 Deductible, $5,000 Out-of-Pocket Maximum
- PLAN D-$5,000 Deductible, $10,000 Out-of-Pocket Maximum
- PLAN E-$10,000 Deductible, $15,000 Out of Pocket Maximum
- PLAN F-$1,000 Deductible, $2,500 Out-of-Pocket Maximum
- PLAN G-$15,000 Deductible, $25,000 Out-of-Pocket Maximum