Just some basic information
First Name
Last Name
Email
*
Confirmation Email
example@example.com
Baby's Due Date/DOB
Format: MM-DD-YYYY
State of Residence
*
Please Select
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
State you live in
Alabama Insurance Providers
*
Please Select
Aetna
Anthem BlueCross BlueShield
BlueCross BlueShield
Cigna
Humana
Humana Medicaid
Meritain
Oxford
Tricare East - Humana
UMR
UnitedHealthcare
UnitedHealthcare Medicaid
Other
Alaska Insurance Providers
*
Please Select
Aetna
Anthem BlueCross BlueShield
BlueCross BlueShield
Cigna
First Choice Health
Humana
Humana Medicaid
Meritain
Oxford
Premera
Regence
Tricare West - HealthNet Federal Services
UMR
UnitedHealthcare
UnitedHealthcare Medicaid
Other
Arizona Insurance Providers
*
Please Select
Aetna
Anthem BlueCross BlueShield
BlueCross BlueShield
Cigna
HealthNet OR, WA, AZ
Humana
Humana Medicaid
Meritain
Oxford
Premera
Regence
Tricare West - HealthNet Federal Services
UMR
UnitedHealthcare
UnitedHealthcare Medicaid
Other
Arkansas Insurance Providers
*
Please Select
Aetna
Anthem BlueCross BlueShield
BlueCross BlueShield
Cigna
Humana
Humana Medicaid
Meritain
Oxford
Tricare East - Humana
UMR
UnitedHealthcare
UnitedHealthcare Medicaid
Other
California Insurance Providers
*
Please Select
Aetna
Aetna Better Health CA
Anthem BlueCross BlueShield
Anthem BlueCross CA
Anthem BlueCross CA - Medi-Cal
BlueCross BlueShield
BlueShield CA
California Health & Wellness
CalOptima
CalViva Medi-Cal
Canopy Health
Chinese Community Health Plan
Cigna
Contra Costa Health Plan
HealthNet CA
HealthNet CA - Medi-Cal
Health Plan of San Mateo
Humana
Humana Medicaid
Inland Empire Health Plan (IEHP)
Kaiser
Medi-Cal (Fee for Service)
Meritain
Molina CA
North East Medical Services (NEMS) CA
Optum Medical Group CA
Oxford
Premera
Regence
San Francisco Health Plan
Tricare West - HealthNet Federal Services
UMR
UnitedHealthcare
UnitedHealthcare Medicaid
Western Health Advantage
Other
Colorado Insurance Providers
*
Please Select
Aetna
Anthem BlueCross BlueShield
BlueCross BlueShield
Cigna
First Choice Health
Humana
Humana Medicaid
Kaiser
Meritain
Oxford
Tricare West - HealthNet Federal Services
UMR
UnitedHealthcare
UnitedHealthcare Medicaid
Other
Connecticut Insurance Providers
*
Please Select
Aetna
Anthem BlueCross BlueShield
BlueCross BlueShield
Cigna
Humana
Humana Medicaid
Meritain
Oxford
Tricare East - Humana
UMR
UnitedHealthcare
UnitedHealthcare Medicaid
Other
Washington DC Insurance Providers
*
Please Select
Aetna
Anthem BlueCross BlueShield
BlueCross BlueShield
Cigna
Humana
Humana Medicaid
Kaiser
Meritain
Oxford
Tricare East - Humana
UMR
UnitedHealthcare
UnitedHealthcare Medicaid
Other
Delaware Insurance Providers
*
Please Select
Aetna
Anthem BlueCross BlueShield
BlueCross BlueShield
Cigna
Humana
Humana Medicaid
Meritain
Oxford
Tricare East - Humana
UMR
UnitedHealthcare
UnitedHealthcare Medicaid
Other
Florida Insurance Providers
*
Please Select
Aetna
Anthem BlueCross BlueShield
BlueCross BlueShield
Cigna
Humana
Humana Medicaid
Meritain
Oxford
Tricare East - Humana
UMR
UnitedHealthcare
UnitedHealthcare Medicaid
Other
Georgia Insurance Providers
*
Please Select
Aetna
Anthem BlueCross BlueShield
BlueCross BlueShield
Cigna
Humana
Humana Medicaid
Kaiser
Meritain
Oxford
Tricare East - Humana
UMR
UnitedHealthcare
UnitedHealthcare Medicaid
Other
Hawaii Insurance Providers
*
Please Select
Aetna
Anthem BlueCross BlueShield
BlueCross BlueShield
Cigna
Hawaii Medical Services Association (HMSA)
Humana
Humana Medicaid
Kaiser
Meritain
Oxford
Premera
Regence
Tricare West - HealthNet Federal Services
UMR
UnitedHealthcare
UnitedHealthcare Medicaid
Other
Idaho Insurance Providers
*
Please Select
Aetna
Anthem BlueCross BlueShield
BlueCross BlueShield
Cigna
First Choice Health
Humana
Humana Medicaid
Meritain
Oxford
Premera
Regence
Tricare West - HealthNet Federal Services
UMR
UnitedHealthcare
UnitedHealthcare Medicaid
Other
Illinois Insurance Providers
*
Please Select
Aetna
Anthem BlueCross BlueShield
BlueCross BlueShield
Cigna
Humana
Humana Medicaid
Meritain
Oxford
Tricare East - Humana
UMR
UnitedHealthcare
UnitedHealthcare Medicaid
Other
Indiana Insurance Providers
*
Please Select
Aetna
Anthem BlueCross BlueShield
BlueCross BlueShield
Cigna
Humana
Humana Medicaid
Meritain
Oxford
Tricare East - Humana
UMR
UnitedHealthcare
UnitedHealthcare Medicaid
Other
Iowa Insurance Providers
*
Please Select
Aetna
Anthem BlueCross BlueShield
BlueCross BlueShield
Cigna
Humana
Humana Medicaid
Meritain
Oxford
Tricare East - Humana
Tricare West - HealthNet Federal Services
UMR
UnitedHealthcare
UnitedHealthcare Medicaid
Other
Kansas Insurance Providers
*
Please Select
Aetna
Anthem BlueCross BlueShield
BlueCross BlueShield
Cigna
Humana
Humana Medicaid
Meritain
Oxford
Tricare West - HealthNet Federal Services
UMR
UnitedHealthcare
UnitedHealthcare Medicaid
Other
Kentucky Insurance Providers
*
Please Select
Aetna
Anthem BlueCross BlueShield
BlueCross BlueShield
Cigna
Humana
Humana Medicaid
Meritain
Oxford
Tricare East - Humana
UMR
UnitedHealthcare
UnitedHealthcare Medicaid
Other
Louisiana Insurance Providers
*
Please Select
Aetna
Anthem BlueCross BlueShield
BlueCross BlueShield
Cigna
Humana
Humana Medicaid
Meritain
Oxford
Premera
Regence
Tricare East - Humana
UMR
UnitedHealthcare
UnitedHealthcare Medicaid
Other
Maine Insurance Providers
*
Please Select
Aetna
Anthem BlueCross BlueShield
BlueCross BlueShield
Cigna
Humana
Humana Medicaid
Meritain
Oxford
Tricare East - Humana
UMR
UnitedHealthcare
UnitedHealthcare Medicaid
Other
Maryland Insurance Providers
*
Please Select
Aetna
Anthem BlueCross BlueShield
BlueCross BlueShield
Cigna
Humana
Humana Medicaid
Kaiser
Meritain
Oxford
Tricare East - Humana
UMR
UnitedHealthcare
UnitedHealthcare Medicaid
Other
Massachusetts Insurance Providers
*
Please Select
Aetna
Anthem BlueCross BlueShield
BlueCross BlueShield
Cigna
Humana
Humana Medicaid
Meritain
Oxford
Tricare East - Humana
UMR
UnitedHealthcare
UnitedHealthcare Medicaid
Other
Michigan Insurance Providers
*
Please Select
Aetna
Anthem BlueCross BlueShield
BlueCross BlueShield
Cigna
Humana
Humana Medicaid
Meritain
Oxford
Tricare East - Humana
UMR
UnitedHealthcare
UnitedHealthcare Medicaid
Other
Minnesota Insurance Providers
*
Please Select
Aetna
Anthem BlueCross BlueShield
BlueCross BlueShield
Cigna
Humana
Humana Medicaid
Meritain
Oxford
Tricare West - HealthNet Federal Services
UMR
UnitedHealthcare
UnitedHealthcare Medicaid
Other
Mississippi Insurance Providers
*
Please Select
Aetna
Anthem BlueCross BlueShield
BlueCross BlueShield
Cigna
Humana
Humana Medicaid
Meritain
Oxford
Tricare East - Humana
UMR
UnitedHealthcare
UnitedHealthcare Medicaid
Other
Missouri Insurance Providers
*
Please Select
Aetna
Anthem BlueCross BlueShield
BlueCross BlueShield
Cigna
Humana
Humana Medicaid
Meritain
Oxford
Tricare East - Humana
Tricare West - HealthNet Federal Services
UMR
UnitedHealthcare
UnitedHealthcare Medicaid
Other
Montana Insurance Providers
*
Please Select
Aetna
Anthem BlueCross BlueShield
BlueCross BlueShield
Cigna
First Choice Health
Humana
Humana Medicaid
Meritain
Oxford
Tricare West - HealthNet Federal Services
UMR
UnitedHealthcare
UnitedHealthcare Medicaid
Other
Nebraska Insurance Providers
*
Please Select
Aetna
Anthem BlueCross BlueShield
BlueCross BlueShield
Cigna
Humana
Humana Medicaid
Meritain
Oxford
Tricare West - HealthNet Federal Services
UMR
UnitedHealthcare
UnitedHealthcare Medicaid
Other
Nevada Insurance Providers
*
Please Select
Aetna
Anthem BlueCross BlueShield
BlueCross BlueShield
Cigna
Humana
Humana Medicaid
Meritain
Oxford
Tricare West - HealthNet Federal Services
UMR
UnitedHealthcare
UnitedHealthcare Medicaid
Other
New Hampshire Insurance Providers
*
Please Select
Aetna
Anthem BlueCross BlueShield
BlueCross BlueShield
Cigna
Humana
Humana Medicaid
Meritain
Oxford
Tricare East - Humana
UMR
UnitedHealthcare
UnitedHealthcare Medicaid
Other
New Jersey Insurance Providers
*
Please Select
Aetna
Anthem BlueCross BlueShield
BlueCross BlueShield
Cigna
Horizon BlueCross BlueShield NJ
Humana
Humana Medicaid
Meritain
Oxford
Premera
Regence
Tricare East - Humana
UMR
UnitedHealthcare
UnitedHealthcare Medicaid
Other
New Mexico Insurance Providers
*
Please Select
Aetna
Anthem BlueCross BlueShield
BlueCross BlueShield
Cigna
Humana
Humana Medicaid
Meritain
Oxford
Tricare West - HealthNet Federal Services
UMR
UnitedHealthcare
UnitedHealthcare Medicaid
Other
New York Insurance Providers
*
Please Select
Aetna
Anthem BlueCross BlueShield
BlueCross BlueShield
Cigna
Humana
Humana Medicaid
Meritain
Oxford
Tricare East - Humana
UMR
UnitedHealthcare
UnitedHealthcare Medicaid
Other
North Carolina Insurance Providers
*
Please Select
Aetna
Anthem BlueCross BlueShield
BlueCross BlueShield
Cigna
Humana
Humana Medicaid
Meritain
Oxford
Premera
Regence
Tricare East - Humana
UMR
UnitedHealthcare
UnitedHealthcare Medicaid
Other
North Dakota Insurance Providers
*
Please Select
Aetna
Anthem BlueCross BlueShield
BlueCross BlueShield
Cigna
First Choice Health
Humana
Humana Medicaid
Meritain
Oxford
Tricare West - HealthNet Federal Services
UMR
UnitedHealthcare
UnitedHealthcare Medicaid
Other
Ohio Insurance Providers
*
Please Select
Aetna
Anthem BlueCross BlueShield
BlueCross BlueShield
Cigna
Humana
Humana Medicaid
Meritain
Oxford
Tricare East - Humana
UMR
UnitedHealthcare
UnitedHealthcare Medicaid
Other
Oklahoma Insurance Providers
*
Please Select
Aetna
Anthem BlueCross BlueShield
BlueCross BlueShield
Cigna
Humana
Humana Medicaid
Meritain
Oxford
Tricare East - Humana
UMR
UnitedHealthcare
UnitedHealthcare Medicaid
Other
Oregon Insurance Providers
*
Please Select
Aetna
Anthem BlueCross BlueShield
BlueCross BlueShield
Cigna
First Choice Health
HealthNet OR, WA, AZ
Humana
Humana Medicaid
Kaiser
Lifewise
Meritain
Oxford
Premera
Regence
Tricare West - HealthNet Federal Services
UMR
UnitedHealthcare
UnitedHealthcare Medicaid
Other
Pennsylvania Insurance Providers
*
Please Select
Aetna
Anthem BlueCross BlueShield
BlueCross BlueShield
Cigna
Humana
Humana Medicaid
Meritain
Oxford
Tricare East - Humana
UMR
UnitedHealthcare
UnitedHealthcare Medicaid
Other
Rhode Island Insurance Providers
*
Please Select
Aetna
Anthem BlueCross BlueShield
BlueCross BlueShield
Cigna
Humana
Humana Medicaid
Meritain
Oxford
Tricare East - Humana
UMR
UnitedHealthcare
UnitedHealthcare Medicaid
Other
South Carolina Insurance Providers
*
Please Select
Aetna
Anthem BlueCross BlueShield
BlueCross BlueShield
Cigna
Humana
Humana Medicaid
Meritain
Oxford
Tricare East - Humana
UMR
UnitedHealthcare
UnitedHealthcare Medicaid
Other
South Dakota Insurance Providers
*
Please Select
Aetna
Anthem BlueCross BlueShield
BlueCross BlueShield
Cigna
Humana
Humana Medicaid
Meritain
Oxford
Tricare West - HealthNet Federal Services
UMR
UnitedHealthcare
UnitedHealthcare Medicaid
Other
Tennessee Insurance Providers
*
Please Select
Aetna
Anthem BlueCross BlueShield
BlueCross BlueShield
Cigna
Humana
Humana Medicaid
Meritain
Oxford
Tricare East - Humana
UMR
UnitedHealthcare
UnitedHealthcare Medicaid
Other
Texas Insurance Providers
*
Please Select
Aetna
Amerigroup TX
Anthem BlueCross BlueShield
BlueCross BlueShield
Cigna
Humana
Humana Medicaid
Meritain
Molina TX
Oxford
Parkland Community Health Plan TX
Premera
Regence
Sendero - IdealCare
Tricare East - Humana
Tricare West - HealthNet Federal Services
UMR
UnitedHealthcare
UnitedHealthcare Medicaid
Other
Utah Insurance Providers
*
Please Select
Aetna
Anthem BlueCross BlueShield
BlueCross BlueShield
Cigna
Humana
Humana Medicaid
Meritain
Oxford
Premera
Regence
Tricare West - HealthNet Federal Services
UMR
UnitedHealthcare
UnitedHealthcare Medicaid
Other
Vermont Insurance Providers
*
Please Select
Aetna
Anthem BlueCross BlueShield
BlueCross BlueShield
Cigna
Humana
Humana Medicaid
Meritain
Oxford
Tricare East - Humana
UMR
UnitedHealthcare
UnitedHealthcare Medicaid
Other
Virginia Insurance Providers
*
Please Select
Aetna
Anthem BlueCross BlueShield
BlueCross BlueShield
Cigna
Humana
Humana Medicaid
Kaiser
Meritain
Oxford
Tricare East - Humana
UMR
UnitedHealthcare
UnitedHealthcare Medicaid
Other
Washington Insurance Providers
*
Please Select
Aetna
Anthem BlueCross BlueShield
BlueCross BlueShield
Cigna
First Choice Health
HealthNet OR, WA, AZ
Humana
Humana Medicaid
Kaiser
Lifewise
Meritain
Molina WA
Oxford
Premera
Regence
Tricare West - HealthNet Federal Services
UMR
UnitedHealthcare
UnitedHealthcare Medicaid
Other
West Virginia Insurance Providers
*
Please Select
Aetna
Anthem BlueCross BlueShield
BlueCross BlueShield
Cigna
Humana
Humana Medicaid
Meritain
Oxford
Tricare East - Humana
UMR
UnitedHealthcare
UnitedHealthcare Medicaid
Other
Wisconsin Insurance Providers
*
Please Select
Aetna
Anthem BlueCross BlueShield
BlueCross BlueShield
Cigna
Humana
Humana Medicaid
Meritain
Oxford
Tricare East - Humana
UMR
UnitedHealthcare
UnitedHealthcare Medicaid
Other
Wyoming Insurance Providers
*
Please Select
Aetna
Anthem BlueCross BlueShield
BlueCross BlueShield
Cigna
First Choice Health
Humana
Humana Medicaid
Meritain
Oxford
Tricare West - HealthNet Federal Services
UMR
UnitedHealthcare
UnitedHealthcare Medicaid
Other
What are the first three characters in your Member ID?
*
Does your insurance card identify or list one of these Medical Groups?
*
Please Select
Optum Medical Group CA
Optum RX
No
Does your insurance card identify or list Regal Medical Group?
Please Select
Yes
No
Does your insurance card identify or list one of these Medical Groups?
*
Please Select
Optum Medical Group CA
Optum RX
Regal Medical Group
No
Does your insurance card identify or list any of the following?
*
Please Select
Optum Medical Group CA
Optum RX
No
What are the first two characters in your Member ID?
*
What are the first two characters in your Member ID?
*
What are the first two characters in your Member ID?
*
What are the first two characters in your Member ID?
*
What is your Member ID?
*
What is your Member ID?
*
Does your card say PIMA, Aliance or Acclaim?
*
Please Select
Yes
No
What is your UnitedHealthCare medical group?
*
Please Select
Canopy
Optum Medical Group CA
Optum RX
Not Listed
What is your Western Health Advantage medical group?
*
Please Select
Northbay Medical Group
MarinHealth Medical Center
Sonoma Valley Hospital
Canopy Health
Not Listed
What is your zip code?
What type of plan do you have?
*
Please Select
PPO
HMO
EPO
Not Sure
Does your Member ID start with any of the following letters?
*
Please Select
ZGC
ZGT
Other
What Is Your Primary Insurance Provider?
*
Insurance Provider (Calculated)
Please Select
Aetna
Aetna Better Health CA
Amerigroup TX
Anthem BlueCross BlueShield
Anthem BlueCross CA
Anthem BlueCross CA - Medi-Cal
BlueCross BlueShield
BlueShield CA
California Health & Wellness
CalOptima
CalViva Medi-Cal
Canopy Health
Chinese Community Health Plan
Cigna
Contra Costa Health Plan
First Choice Health
Health Plan of San Mateo
HealthNet CA
HealthNet CA - Medi-Cal
Humana
Inland Empire Health Plan
Kaiser
Medi-Cal (Fee for Service)
Molina CA
Molina TX
North East Medical Services (NEMS) CA
Optum Medical Group CA
Parkland Community Health Plan TX
Regence
San Francisco Health Plan
Sendero - IdealCare
Tricare East - Humana
Tricare West - HealthNet Federal Services
UnitedHealthcare
Western Health Advantage
Other
Out of Network
Insurance Provider
*
Please Select
Premera Blue Cross Blue Shield of Alaska
Premera Blue Cross of Washington
Regence Blue Shield of WA
Blue Cross Blue Shield of HI
Blue Cross Blue Shield of MI
Blue Cross Blue Shield of NC
Blue Cross Blue Shield of TX
Blue Shield of CA
Anthem Blue Cross of CA
Anthem Blue Cross Blue Shield of CO (OON)
Anthem Blue Cross Blue Shield of CT (OON)
Anthem Blue Cross Blue Shield of IN (OON)
Anthem Blue Cross Blue Shield of KY (OON)
Anthem Blue Cross Blue Shield of ME (OON)
Anthem Blue Cross Blue Shield of MO (OON)
Anthem Blue Cross Blue Shield of NH (OON)
Anthem Blue Cross Blue Shield of NV (OON)
Anthem Blue Cross Blue Shield of OH (OON)
Anthem Blue Cross Blue Shield of VA (OON)
Anthem Blue Cross Blue Shield of WI (OON)
Blue Cross Blue Shield of AL (OON)
Blue Cross Blue Shield of AR (OON)
Blue Cross Blue Shield of AZ (OON)
Blue Cross Blue Shield of GA (OON)
Blue Cross Blue Shield of KS (OON)
Blue Cross Blue Shield of Kansas City, MO (OON)
Blue Cross Blue Shield of LA (OON)
Blue Cross Blue Shield of IL (OON)
Blue Cross Blue Shield of MA (OON)
Blue Cross Blue Shield of MN (OON)
Blue Cross Blue Shield of MS (OON)
Blue Cross Blue Shield of MT (OON)
Blue Cross Blue Shield of NB (OON)
Blue Cross Blue Shield of ND (OON)
Blue Cross Blue Shield of NM (OON)
Blue Cross Blue Shield of OK (OON)
Blue Cross Blue Shield of RI (OON)
Blue Cross Blue Shield of SC (OON)
Blue Cross Blue Shield of TN (OON)
Blue Cross Blue Shield of VT (OON)
Blue Cross Blue Shield of Western NY (OON)
Blue Cross Blue Shield of WY (OON)
Blue Cross of ID (OON)
Blue Cross of Northeast PA (OON)
Blue Shield of Northeast NY (OON)
Capital Blue Cross of Central PA (OON)
CareFirst Blue Cross Blue Shield of DC (OON)
CareFirst Blue Cross Blue Shield of MD (OON)
CareFirst Blue Cross Blue Shield of VA (OON)
Empire Blue Cross Blue Shield of NY (OON)
Excellus Blue Cross Blue Shield (OON)
Florida Blue – Blue Cross Blue Shield of FL (OON)
Highmark Blue Cross Blue Shield of DE (OON)
Highmark Blue Cross Blue Shield of Western PA (OON)
Highmark Blue Cross Blue Shield of WV (OON)
Highmark Blue Shield of NE, E, and Central PA (OON)
Horizon Blue Cross Blue Shield of NJ (OON)
Independence Blue Cross (OON)
Regence Blue Cross Blue Shield of OR (OON)
Regence Blue Cross Blue Shield of UT (OON)
Regence Blue Shield of ID (OON)
Triple S Blue Cross Blue Shield of PR (OON)
Wellmark Blue Cross Blue Shield of IA (OON)
Wellmark Blue Cross Blue Shield of SD (OON)
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