Join Now: Forms & Brochures
For Individuals
Plan 411 Brochure
Plan 460 Brochure
Plan 595 Brochure
For Providers
Specialty Referral
Upgraded/Optional Treatment Form
Patient Encounter Form
For Brokers
Agent Appointment/Contracting Papers
Agent Supply Request
Request for Proposal
Group Application
Advantage Plan Brochures
Benefit Schedules
Plan 100 Schedule
Plan 300 Schedule
Plan 303 Schedule
Plan 340 Schedule
Plan 395 Schedule
Plan 404 Schedule
Plan 411 Schedule
Plan 430 Schedule
Plan 460 Schedule (Group)
Plan 460 Schedule (Individual)
Plan 465 Schedule (Group)
Plan 465 Schedule (Individual)
Plan 495 Schedule
Plan 501 Schedule
Plan 505 Schedule
Cosmetic Benefits Rider for 595 Plan
Plan 530 Schedule
Plan 595 Schedule
Plan 600 Schedule
Plan 665 Schedule
UABT Basic Schedule
UABT Choice Schedule
UABT Prime Schedule
Advantage Plan 75 Schedule
Advantage Plan 100 Schedule
Advantage Plan 150 Schedule
Advantage Plan 200 Schedule
Advantage Plan 250 Schedule
Advantage Plus Plan 75 Schedule
Advantage Plus Plan 100 Schedule
Advantage Plus Plan 150 Schedule
Advantage Plus Plan 200 Schedule
Advantage Plus Plan 250 Schedule
CDN Covered CA Family Dental HMO Benefits/Copayments 2023