EB Enrollment Forms

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EB Enrollment Forms

Your Current Plan	Your Desired Plan	Necessary Forms	When you can make the change
Anthem SmartValue PFFS Plan	Change between SmartValue PFFS Options (Low to High, High to Base, etc.)	2010 EB Plan Election Change Form Anthem SmartValue PFFS Enrollment Form indicating 2010 plan selection.	During Open Enrollment only
Navy POS	Anthem Retiree Medical Plan F and Health Net Rx Anthem SmartValue PFFS & Health Net Rx	2010 EB Plan Election Change Form Health Net Disenrollment form Anthem Retiree Medical Plan F or Anthem SmartValue PFFS Enrollment Form Health Net Orange Rx Enrollment Form	During Open Enrollment Once during the year
Anthem Retiree Medical Plan F or Anthem SmartValue PFFS Plan	Health Net Navy POS Health Net Ruby HMO	2010 EB Plan Election Change Form Health Net Orange Rx Disenrollment Form Health Net Medicare Group Enrollment Form	During Open Enrollment Once during the year
Anthem SmartValue PFFS Plan	Anthem Retiree Medical Plan F	2010 EB Plan Election Change Form Anthem Retiree Medical Plan F Enrollment Form	During Open Enrollment Once during the year
Anthem Retiree Medical Plan F	Anthem SmartValue PFFS Plan (High, Base or Low)	2010 EB Plan Election Change Form Anthem SmartValue PFFS Enrollment Form	During Open Enrollment Once during the year
Health Net Navy POS	Health Net Ruby HMO	2010 EB Plan Election Change Form	During Open Enrollment only
Health Net Unlimited Prescription Drug Plan	Health Net Limited Drug Plan	2010 EB Plan Election Change Form Health Net Orange Rx Opt Down Form	During Open Enrollment only

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