Aetna

Form Name	Effective Date	Download Form
New Group Submission
New Business Submission Checklist 1.23	01/01/2023	Download
New Business Submission Checklist 1.22	01/01/2022	Download
Employer Application 1.23	01/01/2023	Download
Employer Application 1.22	06/01/2022	Download
Small Group ACA Banking Consent Form	01/01/2022	Download
In Force Group Forms
Cal-COBRA Employer Notice of Qualifying Event Form	03/01/2022	Download
Employer Verification Form	01/01/2022	Download
Small Employer Certification Form (FTE Certification)	01/01/2022	Download
Administration
Employer Administrative Handbook	02/01/2023	Download
New Customer Quick Start Guide	01/01/2022	Download

Form Name	Effective Date	Download Form
Enrollment and Change Forms
Employee Enrollment Change Form 1.23	01/01/2023	Download
Employee Enrollment Change Form 1.22	01/01/2022	Download
Request for Continuation of Coverage for Disabled Child	01/01/2022	Download
Disabled Child Attending Physician Statement	01/01/2022	Download
Transition of Care Form (HMO)	01/01/2022	Download
Transition of Care Form (PPO)	01/01/2022	Download
Claim Forms
Authorization to Release Protected Health Information Form	01/01/2022	Download
Medical Claim Form	01/01/2022	Download
Pharmacy Claim Form	01/01/2022	Download
Mail Order Rx Delivery-Registration Form	01/01/2022	Download
Dental Claim Form	01/01/2022	Download
Vision Claim Form (Benefits within a Medical Plan)	01/01/2022	Download
Vision Claim Form (Benefits through Aetna Vision Preferred Plan)	01/01/2022	Download

Form Name	Effective Date	Download Form
2023 Medical HMO
Full HMO Network
HMO Platinum CA $20/40 0 Ded	01/01/2023	Summary	SBC
HMO Platinum CA $20/40 0 Ded wINF	01/01/2023	Summary	SBC
HMO Gold CA $30/60 0 Ded	01/01/2023	Summary	SBC
HMO Gold CA $30/60 0 Ded wINF	01/01/2023	Summary	SBC
HMO Gold CA $35/65 250 Ded	01/01/2023	Summary	SBC
HMO Gold CA $35/65 250 Ded wINF	01/01/2023	Summary	SBC
HMO Gold CA $25/50 500 Ded	01/01/2023	Summary	SBC
HMO Gold CA $25/50 500 Ded wINF	01/01/2023	Summary	SBC
HMO Gold CA $30/70 1250 Ded	01/01/2023	Summary	SBC
HMO Gold CA $30/70 1250 Ded wINF	01/01/2023	Summary	SBC
HMO Silver CA $50/70 0 Ded	01/01/2023	Summary	SBC
HMO Silver CA $50/70 0 Ded wINF	01/01/2023	Summary	SBC
HMO Silver CA $60/100 2500 Ded	01/01/2023	Summary	SBC
HMO Silver CA $60/100 2500 Ded wINF	01/01/2023	Summary	SBC
HMO Bronze CA $75/125 7900 Ded	01/01/2023	Summary	SBC
HMO Bronze CA $75/125 7900 Ded wINF	01/01/2023	Summary	SBC
Aetna Value Network
Aetna Value Network HMO Platinum CA $20/30 0 Ded M	01/01/2023	Summary	SBC
Aetna Value Network HMO Platinum CA $20/30 0 Ded wINF	01/01/2023	Summary	SBC
Aetna Value Network HMO Platinum CA $20/40 0 Ded	01/01/2023	Summary	SBC
Aetna Value Network HMO Platinum CA $20/40 0 Ded wINF	01/01/2023	Summary	SBC
Aetna Value Network HMO Gold CA $30/60 0 Ded	01/01/2023	Summary	SBC
Aetna Value Network HMO Gold CA $30/60 0 Ded wINF	01/01/2023	Summary	SBC
Aetna Value Network HMO Gold CA $35/55 250 Ded M	01/01/2023	Summary	SBC
Aetna Value Network HMO Gold CA $35/55 250 Ded wINF	01/01/2023	Summary	SBC
Aetna Value Network HMO Gold CA $35/65 250 Ded	01/01/2023	Summary	SBC
Aetna Value Network HMO Gold CA $35/65 250 Ded wINF	01/01/2023	Summary	SBC
Aetna Value Network HMO Gold CA $25/50 500 Ded	01/01/2023	Summary	SBC
Aetna Value Network HMO Gold CA $25/50 500 Ded wINF	01/01/2023	Summary	SBC
Aetna Value Network HMO Gold CA $30/70 1250 Ded	01/01/2023	Summary	SBC
Aetna Value Network HMO Gold CA $30/70 1250 Ded wINF	01/01/2023	Summary	SBC
Aetna Value Network HMO Silver CA $50/70 0 Ded	01/01/2023	Summary	SBC
Aetna Value Network HMO Silver CA $50/70 0 Ded wINF	01/01/2023	Summary	SBC
Aetna Value Network HMO Silver CA $55/90 2500 Ded M	01/01/2023	Summary	SBC
Aetna Value Network HMO Silver CA $55/90 2500 Ded wINF	01/01/2023	Summary	SBC
Aetna Value Network HMO Silver CA $60/100 2500 Ded	01/01/2023	Summary	SBC
Aetna Value Network HMO Silver CA $60/100 2500 Ded wINF	01/01/2023	Summary	SBC
Aetna Value Network HMO Bronze CA $75/125 7900 Ded	01/01/2023	Summary	SBC
Aetna Value Network HMO Bronze CA $75/125 7900 Ded wINF	01/01/2023	Summary	SBC
Basic Network
HMO Basic Platinum CA $20/40 0 Ded	01/01/2023	Summary	SBC
HMO Basic Platinum CA $20/40 0 Ded wINF	01/01/2023	Summary	SBC
HMO Basic Gold CA $30/60 0 Ded	01/01/2023	Summary	SBC
HMO Basic Gold CA $30/60 0 Ded wINF	01/01/2023	Summary	SBC
HMO Basic Gold CA $35/65 250 Ded	01/01/2023	Summary	SBC
HMO Basic Gold CA $35/65 250 Ded wINF	01/01/2023	Summary	SBC
HMO Basic Gold CA $25/50 500 Ded	01/01/2023	Summary	SBC
HMO Basic Gold CA $25/50 500 Ded wINF	01/01/2023	Summary	SBC
HMO Basic Gold CA $30/70 1250 Ded	01/01/2023	Summary	SBC
HMO Basic Gold CA $30/70 1250 Ded wINF	01/01/2023	Summary	SBC
HMO Basic Silver CA $50/70 0 Ded	01/01/2023	Summary	SBC
HMO Basic Silver CA $50/70 0 Ded wINF	01/01/2023	Summary	SBC
HMO Basic Silver CA $60/100 2500 Ded	01/01/2023	Summary	SBC
HMO Basic Silver CA $60/100 2500 Ded wINF	01/01/2023	Summary	SBC
HMO Basic Bronze CA $65/95 6300 Ded M	01/01/2023	Summary	SBC
HMO Basic Bronze CA $65/95 6300 Ded wINF	01/01/2023	Summary	SBC
HMO Basic Bronze CA $75/125 7900 Ded	01/01/2023	Summary	SBC
HMO Basic Bronze CA $75/125 7900 Ded wINF	01/01/2023	Summary	SBC
Aetna Whole Health Network Southern CA
AWH Southern CA HMO Platinum CA $20/30 0 Ded M	01/01/2023	Summary	SBC
AWH Southern CA HMO Platinum CA $20/30 0 Ded wINF	01/01/2023	Summary	SBC
AWH Southern CA HMO Platinum CA $20/40 0 Ded	01/01/2023	Summary	SBC
AWH Southern CA HMO Platinum CA $20/40 0 Ded wINF	01/01/2023	Summary	SBC
AWH Southern CA HMO Gold CA $30/60 0 Ded	01/01/2023	Summary	SBC
AWH Southern CA HMO Gold CA $30/60 0 Ded wINF	01/01/2023	Summary	SBC
AWH Southern CA HMO Gold CA $35/55 250 Ded M	01/01/2023	Summary	SBC
AWH Southern CA HMO Gold CA $35/55 250 Ded wINF	01/01/2023	Summary	SBC
AWH Southern CA HMO Gold CA $35/65 250 Ded	01/01/2023	Summary	SBC
AWH Southern CA HMO Gold CA $35/65 250 Ded wINF	01/01/2023	Summary	SBC
AWH Southern CA HMO Gold CA $25/50 500 Ded	01/01/2023	Summary	SBC
AWH Southern CA HMO Gold CA $25/50 500 Ded wINF	01/01/2023	Summary	SBC
AWH Southern CA HMO Gold CA $30/70 1250 Ded	01/01/2023	Summary	SBC
AWH Southern CA HMO Gold CA $30/70 1250 Ded wINF	01/01/2023	Summary	SBC
AWH Southern CA HMO Silver CA $50/70 0 Ded	01/01/2023	Summary	SBC
AWH Southern CA HMO Silver CA $50/70 0 Ded wINF	01/01/2023	Summary	SBC
AWH Southern CA HMO Silver CA $55/90 2500 Ded M	01/01/2023	Summary	SBC
AWH Southern CA HMO Silver CA $55/90 2500 Ded wINF	01/01/2023	Summary	SBC
AWH Southern CA HMO Silver CA $60/100 2500 Ded	01/01/2023	Summary	SBC
AWH Southern CA HMO Silver CA $60/100 2500 Ded wINF	01/01/2023	Summary	SBC
AWH Southern CA HMO Bronze CA $75/125 7900 Ded	01/01/2023	Summary	SBC
AWH Southern CA HMO Bronze CA $75/125 7900 Ded wINF	01/01/2023	Summary	SBC
Aetna Whole Health Network Northern CA
AWH Northern CA HMO Platinum CA $20/30 0 Ded M	01/01/2023	Summary	SBC
AWH Northern CA HMO Platinum CA $20/30 0 Ded wINF	01/01/2023	Summary	SBC
AWH Northern CA HMO Platinum CA $20/40 0 Ded	01/01/2023	Summary	SBC
AWH Northern CA HMO Platinum CA $20/40 0 Ded wINF	01/01/2023	Summary	SBC
AWH Northern CA HMO Gold CA $30/60 0 Ded	01/01/2023	Summary	SBC
AWH Northern CA HMO Gold CA $30/60 0 Ded wINF	01/01/2023	Summary	SBC
AWH Northern CA HMO Gold CA $35/55 250 Ded M	01/01/2023	Summary	SBC
AWH Northern CA HMO Gold CA $35/55 250 Ded wINF	01/01/2023	Summary	SBC
AWH Northern CA HMO Gold CA $35/65 250 Ded	01/01/2023	Summary	SBC
AWH Northern CA HMO Gold CA $35/65 250 Ded wINF	01/01/2023	Summary	SBC
AWH Northern CA HMO Gold CA $25/50 500 Ded	01/01/2023	Summary	SBC
AWH Northern CA HMO Gold CA $25/50 500 Ded wINF	01/01/2023	Summary	SBC
AWH Northern CA HMO Gold CA $30/70 1250 Ded	01/01/2023	Summary	SBC
AWH Northern CA HMO Gold CA $30/70 1250 Ded wINF	01/01/2023	Summary	SBC
AWH Northern CA HMO Silver CA $50/70 0 Ded	01/01/2023	Summary	SBC
AWH Northern CA HMO Silver CA $50/70 0 Ded wINF	01/01/2023	Summary	SBC
AWH Northern CA HMO Silver CA $55/90 2500 Ded M	01/01/2023	Summary	SBC
AWH Northern CA HMO Silver CA $55/90 2500 Ded wINF	01/01/2023	Summary	SBC
AWH Northern CA HMO Silver CA $60/100 2500 Ded	01/01/2023	Summary	SBC
AWH Northern CA HMO Silver CA $60/100 2500 Ded wINF	01/01/2023	Summary	SBC
AWH Northern CA HMO Bronze CA $75/125 7900 Ded	01/01/2023	Summary	SBC
AWH Northern CA HMO Bronze CA $75/125 7900 Ded wINF	01/01/2023	Summary	SBC
2023 Medical PPO
Managed Choice POS Network
OA Managed Choice POS Platinum CA 90/50 0 Ded M	01/01/2023	Summary	SBC
OA Managed Choice POS Platinum CA 90/50 0 Ded wINF	01/01/2023	Summary	SBC
OA Managed Choice POS Platinum CA 80/50 250 Ded	01/01/2023	Summary	SBC
OA Managed Choice POS Platinum CA 80/50 250 Ded wINF	01/01/2023	Summary	SBC
OA Managed Choice POS Gold CA 80/50 350 Ded M	01/01/2023	Summary	SBC
OA Managed Choice POS Gold CA 80/50 350 Ded wINF	01/01/2023	Summary	SBC
OA Managed Choice POS Gold CA 75/50 500 Ded	01/01/2023	Summary	SBC
OA Managed Choice POS Gold CA 75/50 500 Ded wINF	01/01/2023	Summary	SBC
OA Managed Choice POS Gold CA 70/50 1250 Ded	01/01/2023	Summary	SBC
OA Managed Choice POS Gold CA 70/50 1250 Ded wINF	01/01/2023	Summary	SBC
OA Managed Choice POS Gold CA 80/50 1500 Ded	01/01/2023	Summary	SBC
OA Managed Choice POS Gold CA 80/50 1500 Ded wINF	01/01/2023	Summary	SBC
OA Managed Choice POS Gold HDHP CA 90/50 3000 Ded HSA	01/01/2023	Summary	SBC
OA Managed Choice POS Gold HDHP CA 90/50 3000 Ded HSA wINF	01/01/2023	Summary	SBC
OA Managed Choice POS Silver CA 60/50 2100 Ded	01/01/2023	Summary	SBC
OA Managed Choice POS Silver CA 60/50 2100 Ded wINF	01/01/2023	Summary	SBC
OA Managed Choice POS Silver CA Copay Plan 65/50 2500 Ded M	01/01/2023	Summary	SBC
OA Managed Choice POS Silver CA Copay Plan 65/50 2500 Ded wINF	01/01/2023	Summary	SBC
OA Managed Choice POS Silver CA 65/50 2600 Ded	01/01/2023	Summary	SBC
OA Managed Choice POS Silver CA 65/50 2600 Ded wINF	01/01/2023	Summary	SBC
OA Managed Choice POS Bronze CA 55/50 4600 Ded	01/01/2023	Summary	SBC
OA Managed Choice POS Bronze CA 55/50 4600 Ded wINF	01/01/2023	Summary	SBC
OA Managed Choice POS Bronze CA 100/50 7350 Ded	01/01/2023	Summary	SBC
OA Managed Choice POS Bronze CA 100/50 7350 Ded wINF	01/01/2023	Summary	SBC
OA Managed Choice POS Bronze CA 50/50 8300 Ded	01/01/2023	Summary	SBC
OA Managed Choice POS Bronze CA 50/50 8300 Ded wINF	01/01/2023	Summary	SBC
OA Managed Choice POS Bronze HDHP CA 100 7000 Ded HSA M	01/01/2023	Summary	SBC
OA Managed Choice POS Bronze HDHP CA 100 7000 Ded HSA wINF	01/01/2023	Summary	SBC
Savings Plus Managed Choice POS Network
Savings Plus OA Managed Choice POS Platinum CA 90/50 0 Ded M	01/01/2023	Summary	SBC
Savings Plus OA Managed Choice POS Platinum CA 90/50 0 Ded wINF	01/01/2023	Summary	SBC
Savings Plus OA Managed Choice POS Platinum CA 80/50 250 Ded	01/01/2023	Summary	SBC
Savings Plus OA Managed Choice POS Platinum CA 80/50 250 Ded wINF	01/01/2023	Summary	SBC
Savings Plus OA Managed Choice POS Gold CA 80/50 350 Ded M	01/01/2023	Summary	SBC
Savings Plus OA Managed Choice POS Gold CA 80/50 350 Ded wINF	01/01/2023	Summary	SBC
Savings Plus OA Managed Choice POS Gold CA 75/50 500 Ded	01/01/2023	Summary	SBC
Savings Plus OA Managed Choice POS Gold CA 75/50 500 Ded wINF	01/01/2023	Summary	SBC
Savings Plus OA Managed Choice POS Gold CA 70/50 1250 Ded	01/01/2023	Summary	SBC
Savings Plus OA Managed Choice POS Gold CA 70/50 1250 Ded wINF	01/01/2023	Summary	SBC
Savings Plus OA Managed Choice POS Gold CA 80/50 1500 Ded	01/01/2023	Summary	SBC
Savings Plus OA Managed Choice POS Gold CA 80/50 1500 Ded wINF	01/01/2023	Summary	SBC
Savings Plus OA Managed Choice POS Gold HDHP CA 90/50 3000 Ded HSA	01/01/2023	Summary	SBC
Savings Plus OA Managed Choice POS Gold HDHP CA 90/50 3000 Ded HSA wINF	01/01/2023	Summary	SBC
Savings Plus OA Managed Choice POS Silver CA 60/50 2100 Ded	01/01/2023	Summary	SBC
Savings Plus OA Managed Choice POS Silver CA 60/50 2100 Ded wINF	01/01/2023	Summary	SBC
Savings Plus OA Managed Choice POS Silver CA 65/50 2600 Ded	01/01/2023	Summary	SBC
Savings Plus OA Managed Choice POS Silver CA 65/50 2600 Ded wINF	01/01/2023	Summary	SBC
Savings Plus OA Managed Choice POS Silver CA Copay Plan 65/50 2500 Ded M	01/01/2023	Summary	SBC
Savings Plus OA Managed Choice POS Silver CA Copay Plan 65/50 2500 Ded wINF	01/01/2023	Summary	SBC
Savings Plus OA Managed Choice POS Bronze CA 55/50 4600 Ded	01/01/2023	Summary	SBC
Savings Plus OA Managed Choice POS Bronze CA 55/50 4600 Ded wINF	01/01/2023	Summary	SBC
Savings Plus OA Managed Choice POS Bronze CA 100/50 7350 Ded	01/01/2023	Summary	SBC
Savings Plus OA Managed Choice POS Bronze CA 100/50 7350 Ded wINF	01/01/2023	Summary	SBC
Savings Plus OA Managed Choice POS Bronze CA 50/50 8300 Ded	01/01/2023	Summary	SBC
Savings Plus OA Managed Choice POS Bronze CA 50/50 8300 Ded wINF	01/01/2023	Summary	SBC
Savings Plus OA Managed Choice POS Bronze HDHP CA 100 7000 Ded HSA M	01/01/2023	Summary	SBC
Savings Plus OA Managed Choice POS Bronze HDHP CA 100 7000 Ded HSA wINF	01/01/2023	Summary	SBC
Aetna Whole Health Network Southern CA Managed Choice POS Network
AWH Southern CA OA Managed Choice POS Platinum CA 80/50 250 Ded	01/01/2023	Summary	SBC
AWH Southern CA OA Managed Choice POS Platinum CA 80/50 250 Ded wINF	01/01/2023	Summary	SBC
AWH Southern CA OA Managed Choice POS Gold CA 75/50 500 Ded	01/01/2023	Summary	SBC
AWH Southern CA OA Managed Choice POS Gold CA 75/50 500 Ded wINF	01/01/2023	Summary	SBC
AWH Southern CA OA Managed Choice POS Gold CA 70/50 1250 Ded	01/01/2023	Summary	SBC
AWH Southern CA OA Managed Choice POS Gold CA 70/50 1250 Ded wINF	01/01/2023	Summary	SBC
AWH Southern CA OA Managed Choice POS Gold CA 80/50 1500 Ded	01/01/2023	Summary	SBC
AWH Southern CA OA Managed Choice POS Gold CA 80/50 1500 Ded wINF	01/01/2023	Summary	SBC
AWH Southern CA OA Managed Choice POS Gold HDHP CA 90/50 3000 Ded HSA	01/01/2023	Summary	SBC
AWH Southern CA OA Managed Choice POS Gold HDHP CA 90/50 3000 Ded HSA wINF	01/01/2023	Summary	SBC
AWH Southern CA OA Managed Choice POS Silver CA 60/50 2100 Ded	01/01/2023	Summary	SBC
AWH Southern CA OA Managed Choice POS Silver CA 60/50 2100 Ded wINF	01/01/2023	Summary	SBC
AWH Southern CA OA Managed Choice POS Silver CA 65/50 2600 Ded	01/01/2023	Summary	SBC
AWH Southern CA OA Managed Choice POS Silver CA 65/50 2600 Ded wINF	01/01/2023	Summary	SBC
AWH Southern CA OA Managed Choice POS Bronze CA 55/50 4600 Ded	01/01/2023	Summary	SBC
AWH Southern CA OA Managed Choice POS Bronze CA 55/50 4600 Ded wINF	01/01/2023	Summary	SBC
AWH Southern CA OA Managed Choice POS Bronze CA 100/50 7350 Ded	01/01/2023	Summary	SBC
AWH Southern CA OA Managed Choice POS Bronze CA 100/50 7350 Ded wINF	01/01/2023	Summary	SBC
AWH Southern CA OA Managed Choice POS Bronze CA 50/50 8300 Ded	01/01/2023	Summary	SBC
AWH Southern CA OA Managed Choice POS Bronze CA 50/50 8300 Ded wINF	01/01/2023	Summary	SBC
PPO Network (available to out-of-state employees only)
Open Choice PPO Gold CA 80/50 1000 Ded	01/01/2023	Summary	SBC
Open Choice PPO Gold CA 80/50 1000 Ded wINF	01/01/2023	Summary	SBC
Open Choice PPO Silver CA 60/50 2100 Ded	01/01/2023	Summary	SBC
Open Choice PPO Silver CA 60/50 2100 Ded wINF	01/01/2023	Summary	SBC
Open Choice PPO Bronze CA 55/50 4600 Ded	01/01/2023	Summary	SBC
Open Choice PPO Bronze CA 55/50 4600 Ded wINF	01/01/2023	Summary	SBC
Open Choice PPO Bronze CA 50/50 8300 Ded	01/01/2023	Summary	SBC
Open Choice PPO Bronze CA 50/50 8300 Ded wINF	01/01/2023	Summary	SBC
2022 Medical HMO
Full HMO Network
HMO Platinum CA $20/40 0 Ded	01/01/2022	Summary	SBC
HMO Platinum CA $20/40 0 Ded wINF	01/01/2022	Summary	SBC
HMO Gold CA $30/60 0 Ded	01/01/2022	Summary	SBC
HMO Gold CA $30/60 0 Ded wINF	01/01/2022	Summary	SBC
HMO Gold CA $35/65 250 Ded	01/01/2022	Summary	SBC
HMO Gold CA $35/65 250 Ded wINF	01/01/2022	Summary	SBC
HMO Gold CA $25/50 500 Ded	01/01/2022	Summary	SBC
HMO Gold CA $25/50 500 Ded wINF	01/01/2022	Summary	SBC
HMO Gold CA $30/70 1250 Ded	01/01/2022	Summary	SBC
HMO Gold CA $30/70 1250 Ded wINF	01/01/2022	Summary	SBC
HMO Silver CA $50/70 0 Ded	01/01/2022	Summary	SBC
HMO Silver CA $50/70 0 Ded wINF	01/01/2022	Summary	SBC
HMO Silver CA $55/90 2500 Ded	01/01/2022	Summary	SBC
HMO Silver CA $55/90 2500 Ded wINF	01/01/2022	Summary	SBC
HMO Bronze CA $75/125 7900 Ded	01/01/2022	Summary	SBC
HMO Bronze CA $75/125 7900 Ded wINF	01/01/2022	Summary	SBC
Aetna Value Network
Aetna Value Network HMO Platinum CA $20/30 0 Ded	01/01/2022	Summary	SBC
Aetna Value Network HMO Platinum CA $20/30 0 Ded wINF	01/01/2022	Summary	SBC
Aetna Value Network HMO Platinum CA $20/40 0 Ded	01/01/2022	Summary	SBC
Aetna Value Network HMO Platinum CA $20/40 0 Ded wINF	01/01/2022	Summary	SBC
Aetna Value Network HMO Gold CA $30/60 0 Ded	01/01/2022	Summary	SBC
Aetna Value Network HMO Gold CA $30/60 0 Ded wINF	01/01/2022	Summary	SBC
Aetna Value Network HMO Gold CA $35/55 250 Ded	01/01/2022	Summary	SBC
Aetna Value Network HMO Gold CA $35/55 250 Ded wINF	01/01/2022	Summary	SBC
Aetna Value Network HMO Gold CA $35/65 250 Ded	01/01/2022	Summary	SBC
Aetna Value Network HMO Gold CA $35/65 250 Ded wINF	01/01/2022	Summary	SBC
Aetna Value Network HMO Gold CA $25/50 500 Ded	01/01/2022	Summary	SBC
Aetna Value Network HMO Gold CA $25/50 500 Ded wINF	01/01/2022	Summary	SBC
Aetna Value Network HMO Gold CA $30/70 1250 Ded	01/01/2022	Summary	SBC
Aetna Value Network HMO Gold CA $30/70 1250 Ded wINF	01/01/2022	Summary	SBC
Aetna Value Network HMO Silver CA $50/70 0 Ded	01/01/2022	Summary	SBC
Aetna Value Network HMO Silver CA $50/70 0 Ded wINF	01/01/2022	Summary	SBC
Aetna Value Network HMO Silver CA $55/90 2250 Ded	01/01/2022	Summary	SBC
Aetna Value Network HMO Silver CA $55/90 2250 Ded wINF	01/01/2022	Summary	SBC
Aetna Value Network HMO Silver CA $55/90 2500 Ded	01/01/2022	Summary	SBC
Aetna Value Network HMO Silver CA $55/90 2500 Ded wINF	01/01/2022	Summary	SBC
Aetna Value Network HMO Bronze CA $75/125 7900 Ded	01/01/2022	Summary	SBC
Aetna Value Network HMO Bronze CA $75/125 7900 Ded wINF	01/01/2022	Summary	SBC
Basic Network
HMO Basic Platinum CA $20/40 0 Ded	01/01/2022	Summary	SBC
HMO Basic Platinum CA $20/40 0 Ded wINF	01/01/2022	Summary	SBC
HMO Basic Gold CA $30/60 0 Ded	01/01/2022	Summary	SBC
HMO Basic Gold CA $30/60 0 Ded wINF	01/01/2022	Summary	SBC
HMO Basic Gold CA $35/65 250 Ded	01/01/2022	Summary	SBC
HMO Basic Gold CA $35/65 250 Ded wINF	01/01/2022	Summary	SBC
HMO Basic Gold CA $25/50 500 Ded	01/01/2022	Summary	SBC
HMO Basic Gold CA $25/50 500 Ded wINF	01/01/2022	Summary	SBC
HMO Basic Gold CA $30/70 1250 Ded	01/01/2022	Summary	SBC
HMO Basic Gold CA $30/70 1250 Ded wINF	01/01/2022	Summary	SBC
HMO Basic Silver CA $50/70 0 Ded	01/01/2022	Summary	SBC
HMO Basic Silver CA $50/70 0 Ded wINF	01/01/2022	Summary	SBC
HMO Basic Silver CA $55/90 2500 Ded	01/01/2022	Summary	SBC
HMO Basic Silver CA $55/90 2500 Ded wINF	01/01/2022	Summary	SBC
HMO Basic Bronze CA $75/125 7900 Ded	01/01/2022	Summary	SBC
HMO Basic Bronze CA $75/125 7900 Ded wINF	01/01/2022	Summary	SBC
HMO Basic Bronze CA $65/95 6300 Ded - Mandated coverage CA exchange plan (contact RBG for plan availability and rates)	01/01/2022	Summary	SBC
HMO Basic Bronze CA $65/95 6300 Ded wINF - Mandated coverage CA exchange plan (contact RBG for plan availability and rates)	01/01/2022	Summary	SBC
Aetna Whole Health Network Southern CA
AWH Southern CA HMO Platinum CA $20/30 0 Ded	01/01/2022	Summary	SBC
AWH Southern CA HMO Platinum CA $20/30 0 Ded wINF	01/01/2022	Summary	SBC
AWH Southern CA HMO Platinum CA $20/40 0 Ded	01/01/2022	Summary	SBC
AWH Southern CA HMO Platinum CA $20/40 0 Ded wINF	01/01/2022	Summary	SBC
AWH Southern CA HMO Gold CA $30/60 0 Ded	01/01/2022	Summary	SBC
AWH Southern CA HMO Gold CA $30/60 0 Ded wINF	01/01/2022	Summary	SBC
AWH Southern CA HMO Gold CA $35/55 250 Ded	01/01/2022	Summary	SBC
AWH Southern CA HMO Gold CA $35/55 250 Ded wINF	01/01/2022	Summary	SBC
AWH Southern CA HMO Gold CA $35/65 250 Ded	01/01/2022	Summary	SBC
AWH Southern CA HMO Gold CA $35/65 250 Ded wINF	01/01/2022	Summary	SBC
AWH Southern CA HMO Gold CA $25/50 500 Ded	01/01/2022	Summary	SBC
AWH Southern CA HMO Gold CA $25/50 500 Ded wINF	01/01/2022	Summary	SBC
AWH Southern CA HMO Gold CA $30/70 1250 Ded	01/01/2022	Summary	SBC
AWH Southern CA HMO Gold CA $30/70 1250 Ded wINF	01/01/2022	Summary	SBC
AWH Southern CA HMO Silver CA $50/70 0 Ded	01/01/2022	Summary	SBC
AWH Southern CA HMO Silver CA $50/70 0 Ded wINF	01/01/2022	Summary	SBC
AWH Southern CA HMO Silver CA $55/90 2250 Ded	01/01/2022	Summary	SBC
AWH Southern CA HMO Silver CA $55/90 2250 Ded wINF	01/01/2022	Summary	SBC
AWH Southern CA HMO Silver CA $55/90 2500 Ded	01/01/2022	Summary	SBC
AWH Southern CA HMO Silver CA $55/90 2500 Ded wINF	01/01/2022	Summary	SBC
AWH Southern CA HMO Bronze CA $75/125 7900 Ded	01/01/2022	Summary	SBC
AWH Southern CA HMO Bronze CA $75/125 7900 Ded wINF	01/01/2022	Summary	SBC
2022 Medical PPO
Managed Choice POS Network
OA Managed Choice POS Platinum CA 90/50 0 Ded	01/01/2022	Summary	SBC
OA Managed Choice POS Platinum CA 90/50 0 Ded wINF	01/01/2022	Summary	SBC
OA Managed Choice POS Platinum CA 80/50 250 Ded	01/01/2022	Summary	SBC
OA Managed Choice POS Platinum CA 80/50 250 Ded wINF	01/01/2022	Summary	SBC
OA Managed Choice POS Gold CA 80/50 350 Ded	01/01/2022	Summary	SBC
OA Managed Choice POS Gold CA 80/50 350 Ded wINF	01/01/2022	Summary	SBC
OA Managed Choice POS Gold CA 75/50 500 Ded	01/01/2022	Summary	SBC
OA Managed Choice POS Gold CA 75/50 500 Ded wINF	01/01/2022	Summary	SBC
OA Managed Choice POS Gold CA 70/50 1250 Ded	01/01/2022	Summary	SBC
OA Managed Choice POS Gold CA 70/50 1250 Ded wINF	01/01/2022	Summary	SBC
OA Managed Choice POS Gold CA 80/50 1500 Ded	01/01/2022	Summary	SBC
OA Managed Choice POS Gold CA 80/50 1500 Ded wINF	01/01/2022	Summary	SBC
OA Managed Choice POS Gold HDHP CA 90/50 2800 Ded HSA	01/01/2022	Summary	SBC
OA Managed Choice POS Gold HDHP CA 90/50 2800 Ded HSA wINF	01/01/2022	Summary	SBC
OA Managed Choice POS Silver CA 60/50 1700 Ded	01/01/2022	Summary	SBC
OA Managed Choice POS Silver CA 60/50 1700 Ded wINF	01/01/2022	Summary	SBC
OA Managed Choice POS Silver CA 60/50 2000 Ded	01/01/2022	Summary	SBC
OA Managed Choice POS Silver CA 60/50 2000 Ded wINF	01/01/2022	Summary	SBC
OA Managed Choice POS Silver CA Copay Plan 70/50 2250 Ded	01/01/2022	Summary	SBC
OA Managed Choice POS Silver CA Copay Plan 70/50 2250 Ded wINF	01/01/2022	Summary	SBC
OA Managed Choice POS Silver CA 70/50 2500 Ded	01/01/2022	Summary	SBC
OA Managed Choice POS Silver CA 70/50 2500 Ded wINF	01/01/2022	Summary	SBC
OA Managed Choice POS Bronze CA 55/50 4600 Ded	01/01/2022	Summary	SBC
OA Managed Choice POS Bronze CA 55/50 4600 Ded wINF	01/01/2022	Summary	SBC
OA Managed Choice POS Bronze CA 100/50 7350 Ded	01/01/2022	Summary	SBC
OA Managed Choice POS Bronze CA 100/50 7350 Ded wINF	01/01/2022	Summary	SBC
OA Managed Choice POS Bronze CA 50/50 8300 Ded	01/01/2022	Summary	SBC
OA Managed Choice POS Bronze CA 50/50 8300 Ded wINF	01/01/2022	Summary	SBC
OA Managed Choice POS Bronze HDHP CA 100 7000 Ded HSA	01/01/2022	Summary	SBC
OA Managed Choice POS Bronze HDHP CA 100 7000 Ded HSA wINF	01/01/2022	Summary	SBC
Savings Plus Managed Choice POS Network
Savings Plus OA Managed Choice POS Platinum CA 90/50 0 Ded	01/01/2022	Summary	SBC
Savings Plus OA Managed Choice POS Platinum CA 90/50 0 Ded wINF	01/01/2022	Summary	SBC
Savings Plus OA Managed Choice POS Platinum CA 80/50 250 Ded	01/01/2022	Summary	SBC
Savings Plus OA Managed Choice POS Platinum CA 80/50 250 Ded wINF	01/01/2022	Summary	SBC
Savings Plus OA Managed Choice POS Gold CA 80/50 350 Ded	01/01/2022	Summary	SBC
Savings Plus OA Managed Choice POS Gold CA 80/50 350 Ded wINF	01/01/2022	Summary	SBC
Savings Plus OA Managed Choice POS Gold CA 75/50 500 Ded	01/01/2022	Summary	SBC
Savings Plus OA Managed Choice POS Gold CA 75/50 500 Ded wINF	01/01/2022	Summary	SBC
Savings Plus OA Managed Choice POS Gold CA 70/50 1250 Ded	01/01/2022	Summary	SBC
Savings Plus OA Managed Choice POS Gold CA 70/50 1250 Ded wINF	01/01/2022	Summary	SBC
Savings Plus OA Managed Choice POS Gold CA 80/50 1500 Ded	01/01/2022	Summary	SBC
Savings Plus OA Managed Choice POS Gold CA 80/50 1500 Ded wINF	01/01/2022	Summary	SBC
Savings Plus OA Managed Choice POS Gold HDHP CA 90/50 2800 Ded HSA	01/01/2022	Summary	SBC
Savings Plus OA Managed Choice POS Gold HDHP CA 90/50 2800 Ded HSA wINF	01/01/2022	Summary	SBC
Savings Plus OA Managed Choice POS Silver CA 60/50 1700 Ded	01/01/2022	Summary	SBC
Savings Plus OA Managed Choice POS Silver CA 60/50 1700 Ded wINF	01/01/2022	Summary	SBC
Savings Plus OA Managed Choice POS Silver CA 60/50 2000 Ded	01/01/2022	Summary	SBC
Savings Plus OA Managed Choice POS Silver CA 60/50 2000 Ded wINF	01/01/2022	Summary	SBC
Savings Plus OA Managed Choice POS Silver CA Copay Plan 70/50 2250 Ded	01/01/2022	Summary	SBC
Savings Plus OA Managed Choice POS Silver CA Copay Plan 70/50 2250 Ded wINF	01/01/2022	Summary	SBC
Savings Plus OA Managed Choice POS Silver CA 70/50 2500 Ded	01/01/2022	Summary	SBC
Savings Plus OA Managed Choice POS Silver CA 70/50 2500 Ded wINF	01/01/2022	Summary	SBC
Savings Plus OA Managed Choice POS Bronze CA 55/50 4600 Ded	01/01/2022	Summary	SBC
Savings Plus OA Managed Choice POS Bronze CA 55/50 4600 Ded wINF	01/01/2022	Summary	SBC
Savings Plus OA Managed Choice POS Bronze CA 100/50 7350 Ded	01/01/2022	Summary	SBC
Savings Plus OA Managed Choice POS Bronze CA 100/50 7350 Ded wINF	01/01/2022	Summary	SBC
Savings Plus OA Managed Choice POS Bronze CA 50/50 8300 Ded	01/01/2022	Summary	SBC
Savings Plus OA Managed Choice POS Bronze CA 50/50 8300 Ded wINF	01/01/2022	Summary	SBC
Savings Plus OA Managed Choice POS Bronze HDHP CA 100 7000 Ded HSA	01/01/2022	Summary	SBC
Savings Plus OA Managed Choice POS Bronze HDHP CA 100 7000 Ded HSA wINF	01/01/2022	Summary	SBC
Aetna Whole Health Network Southern CA Managed Choice POS Network
AWH Southern CA OA Managed Choice POS Platinum CA 80/50 250 Ded	01/01/2022	Summary	SBC
AWH Southern CA OA Managed Choice POS Platinum CA 80/50 250 Ded wINF	01/01/2022	Summary	SBC
AWH Southern CA OA Managed Choice POS Gold CA 75/50 500 Ded	01/01/2022	Summary	SBC
AWH Southern CA OA Managed Choice POS Gold CA 75/50 500 Ded wINF	01/01/2022	Summary	SBC
AWH Southern CA OA Managed Choice POS Gold CA 70/50 1250 Ded	01/01/2022	Summary	SBC
AWH Southern CA OA Managed Choice POS Gold CA 70/50 1250 Ded wINF	01/01/2022	Summary	SBC
AWH Southern CA OA Managed Choice POS Gold CA 80/50 1500 Ded	01/01/2022	Summary	SBC
AWH Southern CA OA Managed Choice POS Gold CA 80/50 1500 Ded wINF	01/01/2022	Summary	SBC
AWH Southern CA OA Managed Choice POS Gold HDHP CA 90/50 2800 Ded HSA	01/01/2022	Summary	SBC
AWH Southern CA OA Managed Choice POS Gold HDHP CA 90/50 2800 Ded HSA wINF	01/01/2022	Summary	SBC
AWH Southern CA OA Managed Choice POS Silver CA 60/50 1700 Ded	01/01/2022	Summary	SBC
AWH Southern CA OA Managed Choice POS Silver CA 60/50 1700 Ded wINF	01/01/2022	Summary	SBC
AWH Southern CA OA Managed Choice POS Silver CA 60/50 2000 Ded	01/01/2022	Summary	SBC
AWH Southern CA OA Managed Choice POS Silver CA 60/50 2000 Ded wINF	01/01/2022	Summary	SBC
AWH Southern CA OA Managed Choice POS Silver CA 70/50 2500 Ded	01/01/2022	Summary	SBC
AWH Southern CA OA Managed Choice POS Silver CA 70/50 2500 Ded wINF	01/01/2022	Summary	SBC
AWH Southern CA OA Managed Choice POS Bronze CA 55/50 4600 Ded	01/01/2022	Summary	SBC
AWH Southern CA OA Managed Choice POS Bronze CA 55/50 4600 Ded wINF	01/01/2022	Summary	SBC
AWH Southern CA OA Managed Choice POS Bronze CA 100/50 7350 Ded	01/01/2022	Summary	SBC
AWH Southern CA OA Managed Choice POS Bronze CA 100/50 7350 Ded wINF	01/01/2022	Summary	SBC
AWH Southern CA OA Managed Choice POS Bronze CA 50/50 8300 Ded	01/01/2022	Summary	SBC
AWH Southern CA OA Managed Choice POS Bronze CA 50/50 8300 Ded wINF	01/01/2022	Summary	SBC
Sutter Health Network
Sutter OA Managed Choice POS Platinum CA 90/50 0 Ded	01/01/2022	Summary	SBC
Sutter OA Managed Choice POS Platinum CA 90/50 0 Ded wINF	01/01/2022	Summary	SBC
Sutter OA Managed Choice POS Platinum CA 80/50 250 Ded	01/01/2022	Summary	SBC
Sutter OA Managed Choice POS Platinum CA 80/50 250 Ded wINF	01/01/2022	Summary	SBC
Sutter OA Managed Choice POS Gold CA 80/50 350 Ded	01/01/2022	Summary	SBC
Sutter OA Managed Choice POS Gold CA 80/50 350 Ded wINF	01/01/2022	Summary	SBC
Sutter OA Managed Choice POS Gold CA 75/50 500 Ded	01/01/2022	Summary	SBC
Sutter OA Managed Choice POS Gold CA 75/50 500 Ded wINF	01/01/2022	Summary	SBC
Sutter OA Managed Choice POS Gold CA 70/50 1250 Ded	01/01/2022	Summary	SBC
Sutter OA Managed Choice POS Gold CA 70/50 1250 Ded wINF	01/01/2022	Summary	SBC
Sutter OA Managed Choice POS Gold CA 80/50 1500 Ded	01/01/2022	Summary	SBC
Sutter OA Managed Choice POS Gold CA 80/50 1500 Ded wINF	01/01/2022	Summary	SBC
Sutter OA Managed Choice POS Gold HDHP CA 90/50 2800 Ded HSA	01/01/2022	Summary	SBC
Sutter OA Managed Choice POS Gold HDHP CA 90/50 2800 Ded HSA wINF	01/01/2022	Summary	SBC
Sutter OA Managed Choice POS Silver CA 60/50 1700 Ded	01/01/2022	Summary	SBC
Sutter OA Managed Choice POS Silver CA 60/50 1700 Ded wINF	01/01/2022	Summary	SBC
Sutter OA Managed Choice POS Silver CA 60/50 2000 Ded	01/01/2022	Summary	SBC
Sutter OA Managed Choice POS Silver CA 60/50 2000 Ded wINF	01/01/2022	Summary	SBC
Sutter OA Managed Choice POS Silver CA Copay Plan 70/50 2250 Ded	01/01/2022	Summary	SBC
Sutter OA Managed Choice POS Silver CA Copay Plan 70/50 2250 Ded wINF	01/01/2022	Summary	SBC
Sutter OA Managed Choice POS Silver CA 70/50 2500 Ded	01/01/2022	Summary	SBC
Sutter OA Managed Choice POS Silver CA 70/50 2500 Ded wINF	01/01/2022	Summary	SBC
Sutter OA Managed Choice POS Bronze CA 55/50 4600 Ded	01/01/2022	Summary	SBC
Sutter OA Managed Choice POS Bronze CA 55/50 4600 Ded wINF	01/01/2022	Summary	SBC
Sutter OA Managed Choice POS Bronze CA 100/50 7350 Ded	01/01/2022	Summary	SBC
Sutter OA Managed Choice POS Bronze CA 100/50 7350 Ded wINF	01/01/2022	Summary	SBC
Sutter OA Managed Choice POS Bronze CA 50/50 8300 Ded	01/01/2022	Summary	SBC
Sutter OA Managed Choice POS Bronze CA 50/50 8300 Ded wINF	01/01/2022	Summary	SBC
Sutter OA Managed Choice POS Bronze HDHP CA 100 7000 Ded HSA	01/01/2022	Summary	SBC
Sutter OA Managed Choice POS Bronze HDHP CA 100 7000 Ded HSA wINF	01/01/2022	Summary	SBC
PPO Network (available to out-of-state employees only)
Open Choice PPO Gold CA 80/50 1000 Ded	01/01/2022	Summary	SBC
Open Choice PPO Gold CA 80/50 1000 Ded wINF	01/01/2022	Summary	SBC
2021 Medical HMO
Full HMO Network
HMO Platinum CA $20/30 0 Ded	01/01/2021	Summary	SBC
HMO Platinum CA $20/30 0 Ded noINF (without Infertility)	02/01/2021	Summary	SBC
HMO Gold CA $30/60 0 Ded	01/01/2021	Summary	SBC
HMO Gold CA $35/55 250 Ded	01/01/2021	Summary	SBC
HMO Gold CA $35/55 250 Ded noINF (without Infertility)	02/01/2021	Summary	SBC
HMO Gold CA $25/50 500 Ded	01/01/2021	Summary	SBC
HMO Silver CA $55/90 2250 Ded	01/01/2021	Summary	SBC
HMO Silver CA $55/90 2250 Ded noINF (without Infertility)	02/01/2021	Summary	SBC
HMO Silver CA $50/75 2550 Ded	01/01/2021	Summary	SBC
HMO Bronze CA $75/125 7900 Ded	01/01/2021	Summary	SBC
HMO Deductible Network
HMO Deductible Platinum CA $20/30 0 Ded	01/01/2021	Summary	SBC
HMO Deductible Platinum CA $20/30 0 Ded noINF (without Infertility)	02/01/2021	Summary	SBC
HMO Deductible Gold CA $30/60 0 Ded	01/01/2021	Summary	SBC
HMO Deductible Gold CA $35/55 250 Ded	01/01/2021	Summary	SBC
HMO Deductible Gold CA $35/55 250 Ded noINF (without Infertility)	02/01/2021	Summary	SBC
HMO Deductible Gold CA $25/50 500 Ded	01/01/2021	Summary	SBC
HMO Deductible Silver CA $55/90 2250 Ded	01/01/2021	Summary	SBC
HMO Deductible Silver CA $55/90 2250 Ded noINF (without Infertility)	02/01/2021	Summary	SBC
HMO Deductible Silver CA $50/75 2550 Ded	01/01/2021	Summary	SBC
HMO Deductible Bronze CA $75/125 7900 Ded	01/01/2021	Summary	SBC
Aetna Value Network
Aetna Value Network HMO Platinum CA $20/30 0 Ded	01/01/2021	Summary	SBC
Aetna Value Network HMO Platinum CA $20/30 0 Ded noINF (without Infertility)	02/01/2021	Summary	SBC
Aetna Value Network HMO Gold CA $30/60 0 Ded	01/01/2021	Summary	SBC
Aetna Value Network HMO Gold CA $35/55 250 Ded	01/01/2021	Summary	SBC
Aetna Value Network HMO Gold CA $35/55 250 Ded noINF (without Infertility)	02/01/2021	Summary	SBC
Aetna Value Network HMO Gold CA $25/50 500 Ded	01/01/2021	Summary	SBC
Aetna Value Network HMO Silver CA $55/90 2250 Ded	01/01/2021	Summary	SBC
Aetna Value Network HMO Silver CA $55/90 2250 Ded noINF (without Infertility)	02/01/2021	Summary	SBC
Aetna Value Network HMO Silver CA $50/75 2550 Ded	01/01/2021	Summary	SBC
Aetna Value Network HMO Bronze CA $75/125 7900 Ded	01/01/2021	Summary	SBC
Basic Network
HMO Basic Platinum CA $20/30 0 Ded	01/01/2021	Summary	SBC
HMO Basic Platinum CA $20/30 0 Ded noINF (without Infertility)	02/01/2021	Summary	SBC
HMO Basic Gold CA $30/60 0 Ded	01/01/2021	Summary	SBC
HMO Basic Gold CA $35/55 250 Ded	01/01/2021	Summary	SBC
HMO Basic Gold CA $35/55 250 Ded noINF (without Infertility)	02/01/2021	Summary	SBC
HMO Basic Gold CA $25/50 500 Ded	01/01/2021	Summary	SBC
HMO Basic Silver CA $55/90 2250 Ded	01/01/2021	Summary	SBC
HMO Basic Silver CA $55/90 2250 Ded noINF (without Infertility)	02/01/2021	Summary	SBC
HMO Basic Silver CA $50/75 2550 Ded	01/01/2021	Summary	SBC
HMO Basic Bronze CA $75/125 7900 Ded	01/01/2021	Summary	SBC
HMO Basic Bronze CA $65/95 6300 Ded - Mandated coverage CA exchange plan (contact RBG for plan availability and rates)	01/01/2021	Summary	SBC
HMO Basic Bronze CA $65/95 6300 Ded noINF (without Infertility) - Mandated coverage CA exchange plan (contact RBG for plan availability and rates)	02/01/2021	Summary	SBC
Aetna Whole Health Network Southern CA
AWH Southern CA HMO Platinum CA $20/30 0 Ded	01/01/2021	Summary	SBC
AWH Southern CA HMO Platinum CA $20/30 0 Ded noINF (without Infertility)	02/01/2021	Summary	SBC
AWH Southern CA HMO Gold CA $30/60 0 Ded	01/01/2021	Summary	SBC
AWH Southern CA HMO Gold CA $35/55 250 Ded	01/01/2021	Summary	SBC
AWH Southern CA HMO Gold CA $35/55 250 Ded noINF (without Infertility)	02/01/2021	Summary	SBC
AWH Southern CA HMO Gold CA $25/50 500 Ded	01/01/2021	Summary	SBC
AWH Southern CA HMO Silver CA $55/90 2250 Ded	01/01/2021	Summary	SBC
AWH Southern CA HMO Silver CA $55/90 2250 Ded noINF (without Infertility)	02/01/2021	Summary	SBC
AWH Southern CA HMO Silver CA $50/75 2550 Ded	01/01/2021	Summary	SBC
AWH Southern CA HMO Bronze CA $75/125 7900 Ded	01/01/2021	Summary	SBC
2021 Medical EPO
Elect Choice EPO Network
OA Elect Choice EPO Silver CA 60 2000 Ded	01/01/2021	Summary	SBC
Aetna Whole Health Network Southern CA Elect Choice EPO
AWH Southern CA OA Elect Choice EPO Silver CA 60 2000 Ded	01/01/2021	Summary	SBC
2021 Medical PPO
Managed Choice POS Network
OA Managed Choice POS Platinum CA 90/50 0 Ded	01/01/2021	Summary	SBC
OA Managed Choice POS Gold CA 80/50 350 Ded	01/01/2021	Summary	SBC
OA Managed Choice POS Gold CA 80/50 750 Ded	01/01/2021	Summary	SBC
OA Managed Choice POS Gold CA 80/50 1250 Ded	01/01/2021	Summary	SBC
OA Managed Choice POS Gold CA 80/50 1500 Ded	01/01/2021	Summary	SBC
OA Managed Choice POS Silver CA 60/50 2000 Ded	01/01/2021	Summary	SBC
OA Managed Choice POS Silver CA Copay Plan 70/50 2250 Ded	01/01/2021	Summary	SBC
OA Managed Choice POS Silver CA 60/50 2550 Ded	01/01/2021	Summary	SBC
OA Managed Choice POS Bronze CA 60/50 6300 Ded	01/01/2021	Summary	SBC
OA Managed Choice POS Bronze CA 50/50 8300 Ded	01/01/2021	Summary	SBC
OA Managed Choice POS Bronze HDHP CA 100 7000 Ded HSA	01/01/2021	Summary	SBC
Savings Plus Managed Choice POS Network
Savings Plus OA Managed Choice POS Platinum CA 90/50 0 Ded	01/01/2021	Summary	SBC
Savings Plus OA Managed Choice POS Gold CA 80/50 350 Ded	01/01/2021	Summary	SBC
Savings Plus OA Managed Choice POS Gold CA 80/50 750 Ded	01/01/2021	Summary	SBC
Savings Plus OA Managed Choice POS Gold CA 80/50 1250 Ded	01/01/2021	Summary	SBC
Savings Plus OA Managed Choice POS Gold CA 80/50 1500 Ded	01/01/2021	Summary	SBC
Savings Plus OA Managed Choice POS Silver CA 60/50 2000 Ded	01/01/2021	Summary	SBC
Savings Plus OA Managed Choice POS Silver CA Copay Plan 70/50 2250 Ded	01/01/2021	Summary	SBC
Savings Plus OA Managed Choice POS Silver CA 60/50 2550 Ded	01/01/2021	Summary	SBC
Savings Plus OA Managed Choice POS Bronze CA 60/50 6300 Ded	01/01/2021	Summary	SBC
Savings Plus OA Managed Choice POS Bronze CA 50/50 8300 Ded	01/01/2021	Summary	SBC
Savings Plus OA Managed Choice POS Bronze HDHP CA 100 7000 Ded HSA	01/01/2021	Summary	SBC
Aetna Whole Health Network Southern CA Managed Choice POS Network
AWH Southern CA OA Managed Choice POS Platinum CA 90/50 0 Ded	01/01/2021	Summary	SBC
AWH Southern CA OA Managed Choice POS Gold CA 80/50 350 Ded	01/01/2021	Summary	SBC
AWH Southern CA OA Managed Choice POS Gold CA 80/50 750 Ded	01/01/2021	Summary	SBC
AWH Southern CA OA Managed Choice POS Gold CA 80/50 1250 Ded	01/01/2021	Summary	SBC
AWH Southern CA OA Managed Choice POS Gold CA 80/50 1500 Ded	01/01/2021	Summary	SBC
AWH Southern CA OA Managed Choice POS Silver CA 60/50 2000 Ded	01/01/2021	Summary	SBC
AWH Southern CA OA Managed Choice POS Silver CA Copay Plan 70/50 2250 Ded	01/01/2021	Summary	SBC
AWH Southern CA OA Managed Choice POS Silver CA 60/50 2550 Ded	01/01/2021	Summary	SBC
AWH Southern CA OA Managed Choice POS Bronze CA 60/50 6300 Ded	01/01/2021	Summary	SBC
AWH Southern CA OA Managed Choice POS Bronze CA 50/50 8300 Ded	01/01/2021	Summary	SBC
AWH Southern CA OA Managed Choice POS Bronze HDHP CA 100 7000 Ded HSA	01/01/2021	Summary	SBC
PPO Network (available to out-of-state employees only)
Open Choice PPO Gold CA 80/50 1000 Ded	01/01/2021	Summary	SBC

Form Name	Effective Date	Download Form
General Information
CA Small Group Plan Guide - Benefits Toolkit 1.23	01/01/2023	Download
CA Small Group Plan Guide - Benefits Toolkit 5.22	05/01/2022	Download
Underwriting Guidelines 1.23	01/01/2023	Download
Attain by Aetna Member Flyer	03/01/2022	Download
Attain by Aetna FAQ	05/01/2022	Download
Bundle Up Dental & Vision Flyer	06/01/2022	Download
COVID-19 OTC Test POS Plan Sponsor Letter	02/01/2022	Download
California CVS MinuteClinic Flyer	01/01/2022	Download
Discount Program Brochure	01/01/2022	Download
Discount Program Brochure (Post Enrollment)	01/01/2022	Download
Helpful Information & Resources Flyer	01/01/2022	Download
HMO Network Guide 1.23	01/01/2023	Download
California Network Map	01/01/2022	Download
Member Mobile App & Website Flyer	01/01/2022	Download
Online Provider Search Instructions-Full Network HMO	07/01/2022	Download
Online Provider Search Instructions-Aetna Value Network HMO	07/01/2022	Download
Online Provider Search Instructions-Basic Network HMO	07/01/2022	Download
Online Provider Search Instructions-AWH So Cal Network HMO	07/01/2022	Download
Online Provider Search Instructions-OA Managed Choice Network POS	07/01/2022	Download
Online Provider Search Instructions-Savings Plus OA Managed Choice Network POS	07/01/2022	Download
Online Provider Search Instructions-AWH So Cal OA Managed Choice Network POS	07/01/2022	Download
Small Group Prescription Drug Formulary Guide 2022	03/01/2022	Download
Teladoc Pricing Flyer	01/01/2022	Download
Vision Preferred Flyer 1.22 Effective Dates	01/01/2022	Download

Form Name	Effective Date	Download Form
Contact Information	01/01/2022	Download

Aetna

Founded in 1853 in Hartford, CT, Aetna is committed to providing individuals, employers, health care professionals, producers and others with innovative benefits, products and services.

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