| Form Name | Effective Date | Download Form |
|---|---|---|
|
New Group Submission |
||
|
Submission Checklist |
01/01/2020 | Download |
|
Employer Subscription Agreement 1.21 |
01/01/2021 | Download |
|
Medicare Secondary Payer Exception Form (for groups <20 employees) |
01/01/2020 | Download |
|
COBRA Administration Authorization |
01/01/2020 | Download |
|
CalCPA Society Membership Application 5.21 |
05/01/2021 | Download |
|
HealthEquity HSA Employer Implementation Guide |
01/01/2020 | Download |
|
HealthEquity HSA Administration Employer Enrollment |
01/01/2020 | Download |
|
In Force Group Forms |
||
|
Direct Deposit Payment Authorization Form |
01/01/2020 | Download |
|
Electronic Billing Registration Form |
01/01/2020 | Download |
|
Administration |
||
|
Firm Administrator Guide 2.20 |
02/01/2020 | Download |
|
Online Benefits Management Contract Addendum |
01/01/2020 | Download |
|
Online Benefits Management User Registration Form |
01/01/2020 | Download |
|
Open Enrollment FAQ |
01/01/2020 | Download |
| Form Name | Effective Date | Download Form |
|---|---|---|
|
Enrollment and Change Forms |
||
|
Employee Enrollment and Change Form |
10/01/2020 | Download |
|
Continuity of Care | Transition of Care Request Form |
01/01/2020 | Download |
|
HealthEquity HSA Administration Member Enrollment |
01/01/2020 | Download |
|
HealthEquity HSA Beneficiary Designation Form |
01/01/2020 | Download |
|
Health Equity HSA Transfer Information |
01/01/2020 | Download |
|
Health Equity HSA Transfer Form |
01/01/2020 | Download |
|
Claim Forms |
||
|
Anthem HIPAA Authorization |
01/01/2020 | Download |
|
Anthem Medical Claim Form |
01/01/2020 | Download |
|
International Medical Claim Form |
01/01/2020 | Download |
|
Delta Dental Claim Form |
01/01/2020 | Download |
|
Express Scripts Claim Form [for PPO and PPO-HSA plans] |
01/01/2020 | Download |
|
Express Scripts Mail Order Form [for PPO and PPO-HSA plans] |
01/01/2020 | Download |
|
IngenioRx Claim Form [for HMO plans] |
01/01/2020 | Download |
|
IngenioRx Mail Order Form [for HMO plans] |
01/01/2020 | Download |
|
Lincoln LTD Claim Form |
01/01/2020 | Download |
| Form Name | Effective Date | Download Form | |
|---|---|---|---|
|
2023 Medical HMO (plans below are sample documents pending release from carrier) |
|||
|
CaliforniaCare Full HMO Network |
|||
|
Platinum HMO 10/0 |
01/01/2023 | SBC | |
|
Gold HMO 35/0 |
01/01/2023 | SBC | |
|
Silver HMO 25/1500 |
01/01/2023 | SBC | |
|
Silver HMO 30/3000 |
01/01/2023 | SBC | |
|
Select HMO Network |
|||
|
Platinum Select HMO 10/0 |
01/01/2023 | SBC | |
|
Gold Select HMO 35/0 |
01/01/2023 | SBC | |
|
Silver Select HMO 25/1500 |
01/01/2023 | SBC | |
|
Silver Select HMO 30/3000 |
01/01/2023 | SBC | |
|
2023 Medical PPO |
|||
|
Prudent Buyer Full PPO Network (BlueCard Network Out-of-State) |
|||
|
Platinum PPO 10/0 |
01/01/2023 | SBC | |
|
Gold PPO 30/650 |
01/01/2023 | SBC | |
|
Gold PPO 25/750 |
01/01/2023 | SBC | |
|
Gold PPO 30/1000 |
01/01/2023 | SBC | |
|
Gold PPO 35/1250 |
01/01/2023 | SBC | |
|
Silver PPO 45/1850 |
01/01/2023 | SBC | |
|
Silver PPO 45/2250 |
01/01/2023 | SBC | |
|
Silver PPO 50/2500 |
01/01/2023 | SBC | |
|
Silver PPO 45/2850 |
01/01/2023 | SBC | |
|
Silver PPO HSA 1500 |
01/01/2023 | SBC | |
|
Silver PPO HSA 2000 |
01/01/2023 | SBC | |
|
Silver PPO HSA 3000 |
01/01/2023 | SBC | |
|
Silver PPO HSA 3850 |
01/01/2023 | SBC | |
|
Bronze PPO 65/4250 |
01/01/2023 | SBC | |
|
Bronze PPO 50/6250/OV-3 |
01/01/2023 | SBC | |
|
Bronze PPO 75/7250 |
01/01/2023 | SBC | |
|
Bronze PPO HSA 5000 |
01/01/2023 | SBC | |
|
Bronze PPO HSA 6350 |
01/01/2023 | SBC | |
|
Select PPO Network (BlueCard Network Out of State) |
|||
|
Platinum Select PPO 10/0 |
01/01/2023 | SBC | |
|
Gold Select PPO 30/650 |
01/01/2023 | SBC | |
|
Gold Select PPO 25/750 |
01/01/2023 | SBC | |
|
Gold Select PPO 30/1000 |
01/01/2023 | SBC | |
|
Gold Select PPO 35/1250 |
01/01/2023 | SBC | |
|
Silver Select PPO 45/1850 |
01/01/2023 | SBC | |
|
Silver Select PPO 45/2250 |
01/01/2023 | SBC | |
|
Silver Select PPO 50/2500 |
01/01/2023 | SBC | |
|
Silver Select PPO 45/2850 |
01/01/2023 | SBC | |
|
Silver Select PPO HSA 1500 |
01/01/2023 | SBC | |
|
Silver Select PPO HSA 2000 |
01/01/2023 | SBC | |
|
Silver Select PPO HSA 3000 |
01/01/2023 | SBC | |
|
Silver Select PPO HSA 3850 |
01/01/2023 | SBC | |
|
Bronze Select PPO 65/4250 |
01/01/2023 | SBC | |
|
Bronze Select PPO 50/6250/OV-3 |
01/01/2023 | SBC | |
|
Bronze Select PPO 75/7250 |
01/01/2023 | SBC | |
|
Bronze Select PPO HSA 5000 |
01/01/2023 | SBC | |
|
Bronze Select PPO HSA 6350 |
01/01/2023 | SBC | |
|
2023 Medical EPO (plans below are sample documents pending release from carrier) |
|||
|
Gold EPO 25/750 |
01/01/2023 | SBC | |
|
Silver EPO 50/2500 |
01/01/2023 | SBC | |
|
Silver EPO HSA 3000 |
01/01/2023 | SBC | |
|
2022 Medical HMO |
|||
|
CaliforniaCare Full HMO Network |
|||
|
Platinum HMO 10/0 |
01/01/2022 | SBC | |
|
Gold HMO 35/0 |
01/01/2022 | SBC | |
|
Silver HMO 25/1500 |
01/01/2022 | SBC | |
|
Silver HMO 30/3000 |
01/01/2022 | SBC | |
|
Select HMO Network |
|||
|
Platinum Select HMO 10/0 |
01/01/2022 | SBC | |
|
Gold Select HMO 35/0 |
01/01/2022 | SBC | |
|
Silver Select HMO 25/1500 |
01/01/2022 | SBC | |
|
Silver Select HMO 30/3000 |
01/01/2022 | SBC | |
|
2022 Medical PPO |
|||
|
PPO Pediatric Dental & Vision Rider |
|||
|
PPO Pediatric Dental & Vision Benefit Summary |
01/01/2022 | Summary | |
|
Prudent Buyer Full PPO Network (BlueCard Network Out-of-State) |
|||
|
Platinum PPO 10/0 |
01/01/2022 | SBC | |
|
Gold PPO 25/750 |
01/01/2022 | SBC | |
|
Gold PPO 25/1000 |
01/01/2022 | SBC | |
|
Gold PPO 30/650 |
01/01/2022 | SBC | |
|
Gold PPO 35/1250 |
01/01/2022 | SBC | |
|
Silver PPO 40/2000 |
01/01/2022 | SBC | |
|
Silver PPO 45/1650/OV-1 |
01/01/2022 | SBC | |
|
Silver PPO 45/2750/OV-1 |
01/01/2022 | SBC | |
|
Silver PPO 50/2250 |
01/01/2022 | SBC | |
|
Silver PPO HSA 1450 |
01/01/2022 | SBC | |
|
Silver PPO HSA 1950 |
01/01/2022 | SBC | |
|
Silver PPO HSA 2950 |
01/01/2022 | SBC | |
|
Silver PPO HSA 3750 |
01/01/2022 | SBC | |
|
Bronze PPO 50/6000/OV-3 |
01/01/2022 | SBC | |
|
Bronze PPO 65/3950 |
01/01/2022 | SBC | |
|
Bronze PPO 75/7000 |
01/01/2022 | SBC | |
|
Bronze PPO HSA 4950 |
01/01/2022 | SBC | |
|
Bronze PPO HSA 6250 |
01/01/2022 | SBC | |
|
Select PPO Network (BlueCard Network Out of State) |
|||
|
Platinum Select PPO 10/0 |
01/01/2022 | SBC | |
|
Gold Select PPO 25/750 |
01/01/2022 | SBC | |
|
Gold Select PPO 25/1000 |
01/01/2022 | SBC | |
|
Gold Select PPO 30/650 |
01/01/2022 | SBC | |
|
Gold Select PPO 35/1250 |
01/01/2022 | SBC | |
|
Silver Select PPO 40/2000 |
01/01/2022 | SBC | |
|
Silver Select PPO 45/1650/OV-1 |
01/01/2022 | SBC | |
|
Silver Select PPO 45/2750/OV-1 |
01/01/2022 | SBC | |
|
Silver Select PPO 50/2250 |
01/01/2022 | SBC | |
|
Silver Select PPO HSA 1450 |
01/01/2022 | SBC | |
|
Silver Select PPO HSA 1950 |
01/01/2022 | SBC | |
|
Silver Select PPO HSA 2950 |
01/01/2022 | SBC | |
|
Silver Select PPO HSA 3750 |
01/01/2022 | SBC | |
|
Bronze Select PPO 50/6000/OV-3 |
01/01/2022 | SBC | |
|
Bronze Select PPO 65/3950 |
01/01/2022 | SBC | |
|
Bronze Select PPO 75/7000 |
01/01/2022 | SBC | |
|
Bronze Select PPO HSA 4950 |
01/01/2022 | SBC | |
|
Bronze Select PPO HSA 6250 |
01/01/2022 | SBC | |
|
2021 Medical Plan Benefits Comparison |
|||
|
Medical Plan Benefits Comparison Grid |
01/01/2021 | Summary | |
|
2021 Medical HMO |
|||
|
CaliforniaCare Full HMO Network |
|||
|
Platinum HMO 10/0 |
01/01/2021 | SBC | |
|
Gold HMO 35/0 |
01/01/2021 | SBC | |
|
Silver HMO 25/1500 |
01/01/2021 | SBC | |
|
Silver HMO 30/3000 |
01/01/2021 | SBC | |
|
Select HMO Network |
|||
|
Platinum Select HMO 10/0 |
01/01/2021 | SBC | |
|
Gold Select HMO 35/0 |
01/01/2021 | SBC | |
|
Silver Select HMO 25/1500 |
01/01/2021 | SBC | |
|
Silver Select HMO 30/3000 |
01/01/2021 | SBC | |
|
2021 Medical PPO |
|||
|
PPO Pediatric Dental & Vision Rider |
|||
|
PPO Pediatric Dental & Vision Benefit Summary |
01/01/2021 | Summary | |
|
Prudent Buyer Full PPO Network (BlueCard Network Out-of-State) |
|||
|
Platinum PPO 10/0 |
01/01/2021 | SBC | |
|
Gold PPO 20/600 |
01/01/2021 | SBC | |
|
Gold PPO 30/600 |
01/01/2021 | SBC | |
|
Gold PPO 20/1000 |
01/01/2021 | SBC | |
|
Gold PPO 35/1200 |
01/01/2021 | SBC | |
|
Silver PPO 45/1500 |
01/01/2021 | SBC | |
|
Silver PPO 40/2000 |
01/01/2021 | SBC | |
|
Silver PPO 45/2500 |
01/01/2021 | SBC | |
|
Silver PPO HSA 1450 |
01/01/2021 | SBC | |
|
Silver PPO HSA 1900 |
01/01/2021 | SBC | |
|
Silver PPO HSA 2900 |
01/01/2021 | SBC | |
|
Silver PPO HSA 3700 |
01/01/2021 | SBC | |
|
Bronze PPO 65/3900 |
01/01/2021 | SBC | |
|
Bronze PPO 50/6000 Saver |
01/01/2021 | SBC | |
|
Bronze PPO HSA 4900 |
01/01/2021 | SBC | |
|
Bronze PPO HSA 6000 |
01/01/2021 | SBC | |
|
Select PPO Network (BlueCard Network Out-of-State) |
|||
|
Platinum Select PPO 10/0 |
01/01/2021 | SBC | |
|
Gold Select PPO 20/600 |
01/01/2021 | SBC | |
|
Gold Select PPO 30/600 |
01/01/2021 | SBC | |
|
Gold Select PPO 20/1000 |
01/01/2021 | SBC | |
|
Gold Select PPO 35/1200 |
01/01/2021 | SBC | |
|
Silver Select PPO 45/1500 |
01/01/2021 | SBC | |
|
Silver Select PPO 40/2000 |
01/01/2021 | SBC | |
|
Silver Select PPO 45/2500 |
01/01/2021 | SBC | |
|
Silver Select PPO HSA 1450 |
01/01/2021 | SBC | |
|
Silver Select PPO HSA 1900 |
01/01/2021 | SBC | |
|
Silver Select PPO HSA 2900 |
01/01/2021 | SBC | |
|
Silver Select PPO HSA 3700 |
01/01/2021 | SBC | |
|
Bronze Select PPO 65/3900 |
01/01/2021 | SBC | |
|
Bronze Select PPO 50/6000 Saver |
01/01/2021 | SBC | |
|
Bronze Select PPO HSA 4900 |
01/01/2021 | SBC | |
|
Bronze Select PPO HSA 6000 |
01/01/2021 | SBC |
| Form Name | Effective Date | Download Form |
|---|---|---|
|
General Information |
||
|
CalCPA Health 2022 Health Plan Brochure |
01/01/2022 | Download |
|
CalCPA Health 2022 Medical Plan Changes |
01/01/2022 | Download |
|
CalCPA Health Broker Flyer |
01/01/2020 | Download |
|
CalCPA Health Broker PowerPoint Presentation |
01/01/2020 | Download |
|
CalCPA Health Producer Agreement |
06/01/2020 | Download |
|
Helpful Information & Resources Flyer |
01/01/2022 | Download |
|
Underwriting Guidelines |
01/01/2020 | Download |
|
Welcome to CalCPA Health |
01/01/2020 | Download |
|
Anthem Discounts & Special Offers |
01/01/2020 | Download |
|
Anthem Mobile App - Meet Sydney |
01/01/2020 | Download |
|
HealthEquity HSA Employee Brochure |
01/01/2020 | Download |
|
HealthEquity HSA Employer Brochure |
01/01/2020 | Download |
|
Understanding an HSA Flyer |
01/01/2020 | Download |
|
Live Health Online Flyer |
01/01/2020 | Download |
|
Medical |
||
|
Medical Plan Benefits Comparison Grid 2022 |
01/01/2022 | Download |
|
Medical Plan Benefits Comparison Grid 2023 |
01/01/2023 | Download |
|
BlueCard PPO & Global Core Program Flyer |
01/01/2020 | Download |
|
Credit Monitoring Flyer for Medical Members |
01/01/2020 | Download |
|
Estimate Your Costs Tool |
01/01/2020 | Download |
|
Express Scripts Locate a Pharmacy Flyer |
01/01/2020 | Download |
|
Express Scripts Online Access |
01/01/2020 | Download |
|
Online Provider Search Instructions |
01/01/2020 | Download |
|
Rx Formulary - 2019 Anthem Essential 4 Tier [Silver HMO Plans] |
01/01/2020 | Download |
|
Rx Formulary - 2019 Anthem National 4 Tier [Platinum & Gold HMO Plans] |
01/01/2020 | Download |
|
Rx Formulary - 2019 Express Scripts National Preferred [PPO Plans] |
01/01/2020 | Download |
|
Dental |
||
|
Delta Dental Online Access |
01/01/2020 | Download |
|
Delta Dental SmileWay Challenge |
01/01/2020 | Download |
|
Delta Dental Value Add - Amplifon Hearing Health Care |
01/01/2020 | Download |
|
Delta Dental Value Add - QualSight LASIK |
01/01/2020 | Download |
|
Delta Dental Value Added Benefits Employer Flyer |
01/01/2020 | Download |
|
Delta Dental Wellness Resources Calendar |
01/01/2020 | Download |
|
Vision |
||
|
VSP Member Extras - TruHearing Discount |
01/01/2020 | Download |
|
VSP Provider Flyer |
01/01/2020 | Download |
|
VSP Savings Pass |
01/01/2020 | Download |
|
VSP WellVision Exam Flyer |
01/01/2020 | Download |
| Form Name | Effective Date | Download Form |
|---|---|---|
|
Small Group Medical Rate Sheets [effective 1/1/2022] |
01/01/2022 | Download |
|
Ancillary Rate Guides |
||
|
Dental Rate Sheet - Group Size 2 - 4 [effective 1/1/2022] |
01/01/2022 | Download |
|
Dental Rate Sheet - Group Size 5 + [effective 1/1/2022] |
01/01/2022 | Download |
|
Vision Rate Sheet [effective 1/1/2022] |
01/01/2022 | Download |
