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 |
|||
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 |