Materials, Forms and Documents

COSE Benefit Plan Marketing Brochure

CLE-Care Marketing Brochure 

SuperMed Share Plan Marketing Brochure

Dental Selection Flyer (group of 1)

Dental Selection Flyer (2-50 employees)

VSP Vision Savings Pass Overview Flyer

Life and Disability Insurance Plans Brochure (employers with 1-9 employees)

Life and Disability Insurance Plans Brochure (employers with 10+ employees)

Plan Grid Flyer

Member Choice Flyer

Employer Application

Employee Application

Medicare Exception Form

Medicare Exception Form instructions

EFT Form for Group Billing

HSA Set-up Form

HRA Set-up Form

HSA/HRA Contract

Sold Case Pre-Submission Review Form

Transitional Group Checklist

COBRA Addendum/Waiver

COSE and Affiliate Chamber Dues

Affiliate Chambers Map

COSE Benefit Plan Contact List

COSE Benefit Plan FAQ

Compliance Guide

Underwriting Guidelines

Membership & Billing Services Guide 

New Business Affidavit

Self-Employed Individual Affidavit

• Chronic Condition Management Brochure
• COSE Benefit Plan Contact List
• Compliance Guide
• Employee Application
• EmployerLink Flyer
• Find a Provider Flyer
• How to Read Your EOB Brochure
• ID Resolution Flyer
• Make the Most of Your Membership Brochure
• Member FAQ Guide
• Member ID Card Flyer
• Member Online Tools Flyer
• Membership & Billing Services Guide
• Mobile App Flyer
• My Health Plan Flyer
• Mutual Appreciation Program Overview
• MedMutual Pet™ 

Dental Plans

Dental PPO #1 (Employer Sponsored – No Orthodontia)

Dental PPO #1 (Employer Sponsored – With Orthodontia)

Dental PPO #1 (Voluntary – No Orthodontia) 

Dental PPO #2 (Employer Sponsored – No Orthodontia) 

Dental PPO #2 (Employer Sponsored – With Orthodontia) 

Dental PPO #2 (Voluntary – No Orthodontia) 

Dental Value PPO #1 (Employer Sponsored – No Orthodontia) 

Dental Value PPO #1 (Employer Sponsored – With Orthodontia) 

Dental Value PPO #1 (Open Access – No Orthodontia) 

Dental Value PPO #1 (Voluntary – No Orthodontia) 

Dental Value PPO #2 (Employer Sponsored – No Orthodontia) 

Dental Value PPO #2 (Employer Sponsored – With Orthodontia

Dental Value PPO #2 (Open Access – No Orthodontia)

Dental Value PPO #2 (Voluntary – No Orthodontia)

Dental Value PPO #3 (Open Access – No Orthodontia)

Dental Value PPO #3 (Voluntary – No Orthodontia)

Dental PPO #1 (Employer Sponsored – No Orthodontia)

Dental PPO #1 (Employer Sponsored – With Orthodontia)

Dental PPO #1 (Voluntary – No Orthodontia)

Dental PPO #2 (Employer Sponsored – No Orthodontia)

Dental PPO #2 (Employer Sponsored – With Orthodontia)

Dental PPO #2 (Voluntary – No Orthodontia)

Dental Value PPO #1 (Employer Sponsored – No Orthodontia)

Dental Value PPO #1 (Employer Sponsored – With Orthodontia)

Dental Value PPO #1 (Voluntary – No Orthodontia)

Dental Value PPO #2 (Employer Sponsored – No Orthodontia)

Dental Value PPO #2 (Employer Sponsored – With Orthodontia)

Dental Value PPO #2 (Voluntary – No Orthodontia)

Dental Value PPO #3 (Employer Sponsored—No Orthodontia)

Vision Plan

VSP Benefit Highlight Sheet

MedFlex HSA Plans

MedFlex HSA 5000-20 MMRx

MedFlex HSA 5000 PD Rx

MedFlex Plans

MedFlex 3030-2000 MMRx

MedFlex 3030-1000 MMRx

MedFlex 3020-2000 Rx

MedFlex 3020-1000 Rx

HSA Plans

HSA 7500 MMRx

HSA 6550 MMRx

HSA 5000-20 MMRx

HSA 5000 PD Rx

HSA 4000-20 MMRx

HSA 4000 PD Rx

HSA 3500-20 MMRx

HSA 3500 PD Rx

HSA 2500 Agg

CLE-Care HSA Plans

CLE Care HSA 5000-20 MMRx

CLE Care HSA 5000 PD Rx

CLE-Care Plans

CLE Care 3030-2000 MMRx

CLE Care 3030-1000 MMRx

CLE Care 3020-2000 MMRx

CLE Care 3020-1000 MMRx

CLE Care 3020-250 Rx

MMRx Plans

COSE Benefit Plan 9200 MMRx

COSE Benefit Plan 3030-5000 MMRx

COSE Benefit Plan 3030-2000 MMRx

COSE Benefit Plan 3030-1500 MMRx

COSE Benefit Plan 3030-1000 MMRx

Rx Plans

COSE Benefit Plan 3030-0 PD Rx

COSE Benefit Plan 3020-6000 Rx

COSE Benefit Plan 3020-3000 Rx

COSE Benefit Plan 3020-2000 Rx

COSE Benefit Plan 3020-1500 Rx

COSE Benefit Plan 3020-1000 Rx

COSE Benefit Plan 3020-500 Rx

COSE Benefit Plan 3020-250 Rx

COSE Benefit Plan 30-8000 Rx

COSE Benefit Plan 30-5000 Rx

COSE Benefit Plan 30-3500 Rx

COSE Benefit Plan 30-2500 Rx

COSE Benefit Plan 30-2000 Rx

COSE Benefit Plan 30-1000 Rx

COSE Benefit Plan 20-3000 Rx

CLE-Care HMO Plans

CLE Care 3020-250 Rx

CLE Care 3020-1000 Rx

CLE Care 3020-2000 Rx

CLE Care HSA 5000 PDRx

Copay Plans

Copay 020-3000 Rx

Copay 020-5000 Rx

Copay 30-1000 Rx

Copay 30-2000 Rx

Copay 30-3500 Rx

Copay 30-5000 Rx

Copay 30-8000 Rx

Copay 2530-3000 Rx

Copay 2530-4000 Rx

Copay 3020-250 Rx

Copay 3020-500 Rx

Copay 3020-1000 Rx

Copay 3020-1500 Rx

Copay 3020-2000 Rx

Copay 3020-3000 Rx

Copay 3020-6000 Rx

Copay 8700 MMRx

HRA Plans

HRA 30-2000 Rx

HRA 30-3500 Rx

HRA 6500 MMRx

HSA Plans

HSA 2500 MMRx

HSA 3500 PDRx

HSA 3500-30 PDRx

HSA 4000 PDRx

HSA 4000-20 MMRx

HSA 5000 PDRx

HSA 6550 MMRx

HSA 7500 MMRx

MedFlex Plans

MedFlex 3020-250 Rx

MedFlex 3020-1000 Rx

MedFlex 3020-2000 Rx

MedFlex HSA 5000 PDRx

Share Plans

SHARE 3020-1000 Rx

SHARE 3020-1500 Rx

SHARE 3020-2000 Rx

SHARE 3020-3000 Rx

SHARE HSA 3500 PDRx

SHARE HSA 5000 PDRx

CLE-Care HMO Plans

CLE Care 3020-250 Rx

CLE Care 3020-1000 Rx

CLE Care 3020-2000 Rx

CLE Care HSA 5000 PDRx

Copay Plans

Copay 3020-250 Rx

Copay 020-3000 Rx

Copay 020-5000 Rx

Copay 30-1000 Rx

Copay 30-2000 Rx

Copay 30-3500 Rx

Copay 30-5000 Rx

Copay 30-8000 Rx

Copay 2530-3000 Rx

Copay 2530-4000 Rx

Copay 3020-500 Rx

Copay 3020-1000 Rx

Copay 3020-1500 Rx

Copay 3020-2000 Rx

Copay 3020-3000 Rx

Copay 3020-6000 Rx

Copay 8700 MMRx

HRA Plans

HRA 30-2000 Rx

HRA 30-3500 Rx

HRA 6500 MMRx

HSA Plans

HSA 2500 MMRx

HSA 3000 PDRx SHARE

HSA 3000 PDRx

HSA 3000-30 PDRx

HSA 4000 PDRx

HSA 4000-20 MMRx

HSA 5000 PDRx SHARE

HSA 5000 PDRx

HSA 6550 MMRx

HSA 7500 MMRx (effective 8/1/23)

MedFlex Plans

MedFlex 3020-250 Rx

MedFlex 3020-1000 Rx

MedFlex 3020-2000 Rx

MedFlex HSA 5000 PDRx

Share Plans

SHARE 3020-1000 Rx

SHARE 3020-1500 Rx

SHARE 3020-2000 Rx

SHARE 3020-3000 Rx

CLECARE 3020-250 W RX

CLECARE 3020-1000 W RX

CLECARE 3020-2000 W RX

CLECARE HSA 5000 W PD RX

COPAY 020-3000 W RX

COPAY 020-5000 W RX

COPAY 30-1000 W RX

COPAY 30-2000 W RX

COPAY 30-3500 W RX

COPAY 30-5000 W RX

COPAY 30-8000 W RX

COPAY 2530-3000 W RX

COPAY 2530-4000 W RX

COPAY 3020-250 W RX

COPAY 3020-500 W RX

COPAY 3020-1000 W RX

COPAY 3020-1500 W RX

COPAY 3020-2000 W RX

COPAY 3020-3000 W RX

COPAY 3020-6000 W RX

COPAY 8700 W MMRX

HRA 30-2000 W RX

HRA 30-3500 W RX

HRA 6550 W MMRX

HSA 2500 FAM AGG W MMRX

HSA 2500 SIN AGG W MMRX

HSA 3500 W PD RX

HSA 3500-30 W PD COPAY RX

HSA 4000 W PD RX

HSA 4000 W MMRX

HSA 5000 W PD RX

HSA 6550 W MMRX

HSA7500 W MMRX

MEDFLEX 3020-250 W RX

MEDFLEX 3020-1000 W RX

MEDFLEX 3020-2000 W RX

MEDFLEX HSA 5000 W PD RX

CLECARE 3020-250 W RX

CLECARE 3020-1000 W RX

CLECARE 3020-2000 W RX

CLECARE HSA 5000 W PD RX

COPAY 020-3000 W RX

COPAY 020-5000 W RX

COPAY 30-1000 W RX

COPAY 30-2000 W RX

COPAY 30-3500 W RX

COPAY 30-5000 W RX

COPAY 30-8000 W RX

COPAY 2530-3000 W RX

COPAY 2530-4000 W RX

COPAY 3020-250 W RX

COPAY 3020-500 W RX

COPAY 3020-1000 W RX

COPAY 3020-1500 W RX

COPAY 3020-2000 W RX

COPAY 3020-3000 W RX

COPAY 3020-6000 W RX

COPAY 8700 W MMRX

HRA 30-2000 W RX

HRA 30-3500 W RX

HRA 6550 W MMRX

HSA 2500 FAM AGG W MMRX

HSA 2500 SIN AGG W MMRX

HSA 3000 W PD RX

HSA 3000-30 W PD COPAY RX

HSA 4000 W PD RX

HSA 4000-20 W MMRX

HSA 5000 W PD RX

HSA 6550 W MMRX

HSA7500 W MMRX (effective 8/1/23)

MEDFLEX 3020-250 W RX

MEDFLEX 3020-1000 W RX

MEDFLEX 3020-2000 W RX

MEDFLEX HSA 5000 W PD RX