CaliforniaChoice

Form Name	Effective Date	Download Form
New Group Submission
CalChoice Medical Submission Checklist 7.22	07/01/2022	Download
CalChoice Dental/Life Submission Checklist	01/01/2022	Download
Employer Application 1.24 to 4.24 Effective Dates	01/01/2024	Download
Employer Application 7.23 to 12.23 Effective Dates	07/01/2023	Download
Initial Payment Form (ACH) 1.22	01/01/2022	Download
Owner Partner Statement Form	01/01/2022	Download
Case Submission Acknowledgement (for groups submitted after the requested effective date)	01/01/2022	Download
Common Ownership Statement	01/01/2022	Download
Full FSA Election Form	01/01/2022	Download
Group Size Attestation	01/01/2022	Download
Prior Carrier Cancellation Letter Template	01/01/2022	Download
In Force Group Forms
Employee Termination Notification 1.22	01/01/2022	Download
Employer Change Request Form 1.24	01/01/2024	Download
Employer Change Request Form 1.22	01/01/2022	Download
Employer Group Contact Change	01/01/2022	Download
Employer In Force Group Dental Application	01/01/2022	Download
Employer In Force Group Voluntary Vision Application	01/01/2022	Download
Employer Recertification Agreement 1.20 to 12.20 Effective Dates	01/01/2020	Download
Exception Review Request Form-Member Level	07/01/2022	Download
Group COBRA Direct Billing Contract	01/01/2022	Download
Administration
Employer Administrative Guide 4.23	04/01/2023	Download
Employer Program Guide 7.22	07/01/2022	Download

Form Name	Effective Date	Download Form
Enrollment and Change Forms
Employee Enrollment Form 1.24 to 4.24 Effective Dates	01/01/2024	Download
Employee Enrollment Form 7.23 to 12.23 Effective Dates	07/01/2023	Download
Employee Change Request Form 1.24 to 3.24 Effective Dates	01/01/2024	Download
Employee Change Request Form 7.23 to 12.23 Effective Dates	07/01/2023	Download
Disabled Dependent Certification Form	01/01/2022	Download
Affidavit of Domestic Partnership	01/01/2022	Download
COBRA Forms
COBRA Enrollment Application 1.22	01/01/2022	Download
Claim Forms
RX Claim Form - Anthem Express Scripts		Download
RX Claim Form - Health Net	07/01/2022	Download
RX Claim Form - Sharp		Download
RX Claim Form - UHC		Download
RX by Mail Claim Form - Anthem		Download
RX by Mail Claim Form - Health Net		Download
RX by Mail Claim Form - Kaiser		Download
RX by Mail Claim Form - Sharp		Download
RX by Mail Claim Form - UHC		Download

Form Name	Effective Date	Download Form
2024 Medical Plan Benefit Summary Booklets
All Tiers Benefit Summaries 1.24 - 12.23 Effective Dates	01/01/2024	Summary
2023 Medical Plan Benefit Summary Booklets
July - December 2023 Effective Dates
All Tiers Benefit Summaries 7.23 - 12.23 Effective Dates	07/01/2023	Summary
Platinum Benefit Summaries 7.23 - 12.23 Effective Dates	07/01/2023	Summary
Platinum/Gold Benefit Summaries 7.23 - 12.23 Effective Dates	07/01/2023	Summary
Platinum/Gold/Silver Benefit Summaries 7.23 - 12.23 Effective Dates	07/01/2023	Summary
Gold Benefit Summaries 7.23 - 12.23 Effective Dates	07/01/2023	Summary
Gold/Silver Benefit Summaries 7.23 - 12.23 Effective Dates	07/01/2023	Summary
Gold/Silver/Bronze Benefit Summaries 7.23 - 12.23 Effective Dates	07/01/2023	Summary
Silver Benefit Summaries 7.23 - 12.23 Effective Dates	07/01/2023	Summary
Silver/Bronze Benefit Summaries 7.23 - 12.23 Effective Dates	07/01/2023	Summary
Bronze Benefit Summaries 7.23 - 12.23 Effective Dates	07/01/2023	Summary
April - June 2023 Effective Dates
All Tiers Benefit Summaries 4.23 - 6.23 Effective Dates	04/01/2023	Summary
Platinum Benefit Summaries 4.23 - 6.23 Effective Dates	04/01/2023	Summary
Platinum/Gold Benefit Summaries 4.23 - 6.23 Effective Dates	04/01/2023	Summary
Platinum/Gold/Silver Benefit Summaries 4.23 - 6.23 Effective Dates	04/01/2023	Summary
Gold Benefit Summaries 4.23 - 6.23 Effective Dates	04/01/2023	Summary
Gold/Silver Benefit Summaries 4.23 - 6.23 Effective Dates	04/01/2023	Summary
Gold/Silver/Bronze Benefit Summaries 4.23 - 6.23 Effective Dates	04/01/2023	Summary
Silver Benefit Summaries 4.23 - 6.23 Effective Dates	04/01/2023	Summary
Silver/Bronze Benefit Summaries 4.23 - 6.23 Effective Dates	04/01/2023	Summary
Bronze Benefit Summaries 4.23 - 6.23 Effective Dates	04/01/2023	Summary
January - March 2023 Effective Dates
All Tiers Benefit Summaries 1.23 - 3.23 Effective Dates	01/01/2023	Summary
Platinum Benefit Summaries 1.23 - 3.23 Effective Dates	01/01/2023	Summary
Platinum/Gold Benefit Summaries 1.23 - 3.23 Effective Dates	01/01/2023	Summary
Platinum/Gold/Silver Benefit Summaries 1.23 - 3.23 Effective Dates	01/01/2023	Summary
Gold Benefit Summaries 1.23 - 3.23 Effective Dates	01/01/2023	Summary
Gold/Silver Benefit Summaries 1.23 - 3.23 Effective Dates	01/01/2023	Summary
Gold/Silver/Bronze Benefit Summaries 1.23 - 3.23 Effective Dates	01/01/2023	Summary
Silver Benefit Summaries 1.23 - 3.23 Effective Dates	01/01/2023	Summary
Silver/Bronze Benefit Summaries 1.23 - 3.23 Effective Dates	01/01/2023	Summary
Bronze Benefit Summaries 1.23 - 3.23 Effective Dates	01/01/2023	Summary
2023 Medical HMO SBCs
Anthem HMO
Anthem Blue Cross Platinum Select HMO A	01/01/2023		SBC
Anthem Blue Cross Gold Select HMO A	01/01/2023		SBC
Anthem Blue Cross Gold CaliforniaCare HMO B	01/01/2023		SBC
Anthem Blue Cross Gold Priority Select HMO C	01/01/2023		SBC
Anthem Blue Cross Silver Select HMO A	01/01/2023		SBC
Anthem Blue Cross Silver CaliforniaCare HMO B	01/01/2023		SBC
Anthem Blue Cross Silver Priority Select HMO C	01/01/2023		SBC
Health Net HMO
Health Net Platinum WholeCare HMO C	01/01/2023		SBC
Health Net Platinum Salud HMO D	01/01/2023		SBC
Health Net Platinum Full Network HMO E	01/01/2023		SBC
Health Net Platinum Wholecare HMO F	01/01/2023		SBC
Health Net Platinum Salud HMO G	01/01/2023		SBC
Health Net Platinum Full Network HMO H	01/01/2023		SBC
Health Net Platinum SmartCare HMO I	01/01/2023		SBC
Health Net Platinum SmartCare HMO J	01/01/2023		SBC
Health Net Gold WholeCare HMO A	01/01/2023		SBC
Health Net Gold WholeCare HMO B	01/01/2023		SBC
Health Net Gold WholeCare HMO C	01/01/2023		SBC
Health Net Gold Salud HMO D	01/01/2023		SBC
Health Net Gold Full Network HMO E	01/01/2023		SBC
Health Net Gold Full Network HMO F	01/01/2023		SBC
Health Net Gold Full Network HMO G	01/01/2023		SBC
Health Net Gold SmartCare HMO H	01/01/2023		SBC
Health Net Gold SmartCare HMO I	01/01/2023		SBC
Health Net Silver WholeCare HMO A	01/01/2023		SBC
Health Net Silver CommunityCare HMO C	01/01/2023		SBC
Health Net Silver Full Network HMO D	01/01/2023		SBC
Health Net Bronze CommunityCare HMO A	01/01/2023		SBC
Kaiser Permanente HMO
Kaiser Platinum HMO A	01/01/2023		SBC
Kaiser Platinum HMO B	01/01/2023		SBC
Kaiser Gold HMO B	01/01/2023		SBC
Kaiser Gold HMO C	01/01/2023		SBC
Kaiser Gold HMO D	01/01/2023		SBC
Kaiser Gold HMO E (HSA Eligible)	01/01/2023		SBC
Kaiser Silver HMO A	01/01/2023		SBC
Kaiser Silver HMO B	01/01/2023		SBC
Kaiser Silver HMO C	01/01/2023		SBC
Kaiser Silver HMO D (HSA Eligible)	01/01/2023		SBC
Kaiser Silver HMO E	01/01/2023		SBC
Kaiser Bronze HMO A	01/01/2023		SBC
Kaiser Bronze HMO B	01/01/2023		SBC
Kaiser Bronze HMO C (HSA Eligible)	01/01/2023		SBC
Sharp HMO
Sharp Platinum Premier HMO A	01/01/2023		SBC
Sharp Platinum Performance HMO B	01/01/2023		SBC
Sharp Platinum Premier HMO C	01/01/2023		SBC
Sharp Gold Performance HMO A	01/01/2023		SBC
Sharp Gold Premier HMO B	01/01/2023		SBC
Sharp Gold Performance HMO D	01/01/2023		SBC
Sharp Silver Premier HMO A	01/01/2023		SBC
Sharp Silver Performance HMO B	01/01/2023		SBC
Sharp Silver Premier HMO C	01/01/2023		SBC
Sharp Bronze Premier HMO A	01/01/2023		SBC
Sharp Bronze Performance HMO B (HSA Eligible)	01/01/2023		SBC
Sutter Health Plus HMO
Sutter Health Plus Platinum HMO A	01/01/2023		SBC
Sutter Health Plus Platinum HMO B	01/01/2023		SBC
Sutter Health Plus Gold HMO A	01/01/2023		SBC
Sutter Health Plus Gold HMO B	01/01/2023		SBC
Sutter Health Plus Gold HMO C (HSA Eligible)	04/01/2023		SBC
Sutter Health Plus Silver HMO B	01/01/2023		SBC
Sutter Health Plus Silver HMO C (HSA Eligible)	01/01/2023		SBC
Sutter Health Plus Bronze HMO A	01/01/2023		SBC
Sutter Health Plus Bronze HMO B (HSA Eligible)	01/01/2023		SBC
UnitedHealthcare HMO
UHC Platinum SignatureValue HMO A	01/01/2023		SBC
UHC Platinum SignatureValue HMO B	01/01/2023		SBC
UHC Platinum Alliance HMO C	01/01/2023		SBC
UHC Platinum SignatureValue HMO E	01/01/2023		SBC
UHC Platinum Alliance HMO G	01/01/2023		SBC
UHC Platinum Harmony HMO H	01/01/2023		SBC
UHC Platinum Harmony HMO I	01/01/2023		SBC
UHC Platinum Alliance HMO J	01/01/2023		SBC
UHC Platinum Harmony HMO K	01/01/2023		SBC
UHC Platinum SignatureValue HMO L	01/01/2023		SBC
UHC Platinum Harmony HMO M	01/01/2023		SBC
UHC Platinum Alliance HMO N	01/01/2023		SBC
UHC Gold SignatureValue HMO A	01/01/2023		SBC
UHC Gold Alliance HMO B	01/01/2023		SBC
UHC Gold SignatureValue HMO F	01/01/2023		SBC
UHC Gold Alliance HMO G	01/01/2023		SBC
UHC Gold SignatureValue HMO H	01/01/2023		SBC
UHC Gold Alliance HMO J	01/01/2023		SBC
UHC Gold Harmony HMO L	01/01/2023		SBC
UHC Gold Harmony HMO M	01/01/2023		SBC
UHC Gold Harmony HMO N	01/01/2023		SBC
UHC Gold Alliance HMO O	01/01/2023		SBC
UHC Gold Harmony HMO P	01/01/2023		SBC
UHC Gold SignatureValue HMO Q	01/01/2023		SBC
UHC Silver SignatureValue HMO A	01/01/2023		SBC
UHC Silver Alliance HMO E	01/01/2023		SBC
UHC Silver Harmony HMO F	01/01/2023		SBC
UHC Silver Harmony HMO G	01/01/2023		SBC
Western Health Advantage HMO
Western Health Platinum HMO A	01/01/2023		SBC
Western Health Platinum HMO B	01/01/2023		SBC
Western Health Platinum HMO C	01/01/2023		SBC
Western Health Gold HMO A	01/01/2023		SBC
Western Health Gold HMO B	01/01/2023		SBC
Western Health Gold HMO C	01/01/2023		SBC
Western Health Gold HMO D (HSA Eligible)	01/01/2023		SBC
Western Health Silver HMO A	01/01/2023		SBC
Western Health Silver HMO B	01/01/2023		SBC
Western Health Silver HMO C (HSA Eligible)	01/01/2023		SBC
Western Health Bronze HMO B	01/01/2023		SBC
Western Health Bronze HMO C (HSA Eligible)	01/01/2023		SBC
2023 Medical EPO SBCs
Cigna + Oscar EPO
Cigna+Oscar Platinum LocalPlus EPO C	01/01/2023		SBC
Cigna+Oscar Platinum LocalPlus EPO D	01/01/2023		SBC
Cigna+Oscar Platinum LocalPlus EPO E	01/01/2023		SBC
Cigna+Oscar Platinum Open Access Plus EPO F	01/01/2023		SBC
Cigna+Oscar Platinum Open Access Plus EPO G	01/01/2023		SBC
Cigna+Oscar Gold LocalPlus EPO C	01/01/2023		SBC
Cigna+Oscar Gold LocalPlus EPO D	01/01/2023		SBC
Cigna+Oscar Gold LocalPlus EPO E	01/01/2023		SBC
Cigna+Oscar Gold Open Access Plus EPO F	01/01/2023		SBC
Cigna+Oscar Gold Open Access Plus EPO G	01/01/2023		SBC
Cigna+Oscar Silver LocalPlus EPO C	01/01/2023		SBC
Cigna+Oscar Silver LocalPlus EPO D	01/01/2023		SBC
Cigna+Oscar Silver LocalPlus EPO E (HSA Eligible)	01/01/2023		SBC
Cigna+Oscar Silver Open Access Plus EPO F	01/01/2023		SBC
Cigna+Oscar Silver Open Access Plus EPO G (HSA Eligible)	01/01/2023		SBC
Cigna+Oscar Bronze LocalPlus EPO C (HSA Eligible)	01/01/2023		SBC
Cigna+Oscar Bronze LocalPlus EPO D	01/01/2023		SBC
Cigna+Oscar Bronze LocalPlus EPO F	01/01/2023		SBC
Cigna+Oscar Bronze Open Access Plus EPO E	01/01/2023		SBC
2023 Medical PPO SBCs
Anthem Blue Cross PPO
Anthem Blue Cross Platinum PPO A [New 7/1/2023]	07/01/2023		SBC
Anthem Blue Cross Gold Select PPO B	01/01/2023		SBC
Anthem Blue Cross Gold Select PPO C	01/01/2023		SBC
Anthem Blue Cross Gold Select PPO D	01/01/2023		SBC
Anthem Blue Cross Gold PPO E	01/01/2023		SBC
Anthem Blue Cross Gold PPO F [New 7/1/2023]	07/01/2023		SBC
Anthem Blue Cross Gold Select PPO G [New 7/1/2023]	07/01/2023		SBC
Anthem Blue Cross Silver Select PPO B	01/01/2023		SBC
Anthem Blue Cross Silver PPO C	01/01/2023		SBC
Anthem Blue Cross Silver PPO D (HSA Eligible)	01/01/2023		SBC
Anthem Blue Cross Silver Select PPO E (HSA Eligible)	01/01/2023		SBC
Anthem Blue Cross Bronze PPO A (HSA Eligible)	01/01/2023		SBC
Anthem Blue Cross Bronze Select PPO B (HSA Eligible)	01/01/2023		SBC
Anthem Blue Cross Bronze PPO C	01/01/2023		SBC
Anthem Blue Cross Bronze Select PPO D	01/01/2023		SBC
2022 Medical Plan Benefit Summary Booklets
July - December 2022 Effective Dates
All Tiers Benefit Summaries 7.22 - 12.22 Effective Dates	07/01/2022	Summary
Platinum Benefit Summaries 7.22 - 12.22 Effective Dates	07/01/2022	Summary
Platinum/Gold Benefit Summaries 7.22 - 12.22 Effective Dates	07/01/2022	Summary
Platinum/Gold/Silver Benefit Summaries 7.22 - 12.22 Effective Dates	07/01/2022	Summary
Gold Benefit Summaries 7.22 - 12.22 Effective Dates	07/01/2022	Summary
Gold/Silver Benefit Summaries 7.22 - 12.22 Effective Dates	07/01/2022	Summary
Gold/Silver/Bronze Benefit Summaries 7.22 - 12.22 Effective Dates	07/01/2022	Summary
Silver Benefit Summaries 7.22 - 12.22 Effective Dates	07/01/2022	Summary
Silver/Bronze Benefit Summaries 7.22 - 12.22 Effective Dates	07/01/2022	Summary
Bronze Benefit Summaries 7.22 - 12.22 Effective Dates	07/01/2022	Summary
April - June 2022 Effective Dates
All Tiers Benefit Summaries 4.22 - 6.22 Effective Dates	05/01/2022	Summary
Platinum Benefit Summaries 4.22 - 6.22 Effective Dates	05/01/2022	Summary
Platinum/Gold Benefit Summaries 4.22 - 6.22 Effective Dates	05/01/2022	Summary
Platinum/Gold/Silver Benefit Summaries 4.22 - 6.22 Effective Dates	05/01/2022	Summary
Gold Benefit Summaries 4.22 - 6.22 Effective Dates	05/01/2022	Summary
Gold/Silver Benefit Summaries 4.22 - 6.22 Effective Dates	05/01/2022	Summary
Gold/Silver/Bronze Benefit Summaries 4.22 - 6.22 Effective Dates	05/01/2022	Summary
Silver Benefit Summaries 4.22 - 6.22 Effective Dates	05/01/2022	Summary
Silver/Bronze Benefit Summaries 4.22 - 6.22 Effective Dates	05/01/2022	Summary
Bronze Benefit Summaries 4.22 - 6.22 Effective Dates	05/01/2022	Summary
March 2022 Effective Dates
All Tiers Benefit Summaries 3.22 Effective Dates	03/01/2022	Summary
Platinum Benefit Summaries 3.22 Effective Dates	03/01/2022	Summary
Platinum/Gold Benefit Summaries 3.22 Effective Dates	03/01/2022	Summary
Platinum/Gold/Silver Benefit Summaries 3.22 Effective Dates	03/01/2022	Summary
Gold Benefit Summaries 3.22 Effective Dates	03/01/2022	Summary
Gold/Silver Benefit Summaries 3.22 Effective Dates	03/01/2022	Summary
Gold/Silver/Bronze Benefit Summaries 3.22 Effective Dates	03/01/2022	Summary
Silver Benefit Summaries 3.22 Effective Dates	03/01/2022	Summary
Silver/Bronze Benefit Summaries 3.22 Effective Dates	03/01/2022	Summary
Bronze Benefit Summaries 3.22 Effective Dates	03/01/2022	Summary
January - February 2022 Effective Dates
All Tiers Benefit Summaries 1.22 - 2.22 Effective Dates	03/01/2022	Summary
Platinum Benefit Summaries 1.22 - 2.22 Effective Dates	03/01/2022	Summary
Platinum/Gold Benefit Summaries 1.22 - 2.22 Effective Dates	03/01/2022	Summary
Platinum/Gold/Silver Benefit Summaries 1.22 - 2.22 Effective Dates	03/01/2022	Summary
Gold Benefit Summaries 1.22 - 2.22 Effective Dates	03/01/2022	Summary
Gold/Silver Benefit Summaries 1.22 - 2.22 Effective Dates	03/01/2022	Summary
Gold/Silver/Bronze Benefit Summaries 1.22 - 2.22 Effective Dates	03/01/2022	Summary
Silver Benefit Summaries 1.22 - 2.22 Effective Dates	03/01/2022	Summary
Silver/Bronze Benefit Summaries 1.22 - 2.22 Effective Dates	03/01/2022	Summary
Bronze Benefit Summaries 1.22 - 2.22 Effective Dates	03/01/2022	Summary
2022 Medical HMO SBCs
Anthem HMO
Anthem Blue Cross Platinum Select HMO A	01/01/2022		SBC
Anthem Blue Cross Gold Select HMO A	01/01/2022		SBC
Anthem Blue Cross Gold CaliforniaCare HMO B	01/01/2022		SBC
Anthem Blue Cross Gold Priority Select HMO C	03/01/2022		SBC
Anthem Blue Cross Silver Select HMO A	01/01/2022		SBC
Anthem Blue Cross Silver CaliforniaCare HMO B	01/01/2022		SBC
Anthem Blue Cross Silver Priority Select HMO C	03/01/2022		SBC
Health Net HMO
Health Net Platinum WholeCare HMO C	01/01/2022		SBC
Health Net Platinum Salud HMO D	01/01/2022		SBC
Health Net Platinum Full Network HMO E	01/01/2022		SBC
Health Net Platinum Wholecare HMO F	01/01/2022		SBC
Health Net Platinum Salud HMO G	01/01/2022		SBC
Health Net Platinum Full Network HMO H	01/01/2022		SBC
Health Net Gold WholeCare HMO A	01/01/2022		SBC
Health Net Gold WholeCare HMO B	01/01/2022		SBC
Health Net Gold WholeCare HMO C	01/01/2022		SBC
Health Net Gold Salud HMO D	01/01/2022		SBC
Health Net Gold Full Network HMO E	01/01/2022		SBC
Health Net Gold Full Network HMO F	01/01/2022		SBC
Health Net Gold Full Network HMO G	01/01/2022		SBC
Health Net Silver WholeCare HMO A	01/01/2022		SBC
Health Net Silver CommunityCare HMO C	01/01/2022		SBC
Health Net Bronze CommunityCare HMO A	01/01/2022		SBC
Kaiser Permanente HMO
Kaiser Platinum HMO A	01/01/2022		SBC
Kaiser Platinum HMO B	01/01/2022		SBC
Kaiser Gold HMO B	01/01/2022		SBC
Kaiser Gold HMO C	01/01/2022		SBC
Kaiser Gold HMO D	01/01/2022		SBC
Kaiser Gold HMO E (HSA Eligible)	01/01/2022		SBC
Kaiser Silver HMO A	01/01/2022		SBC
Kaiser Silver HMO B	01/01/2022		SBC
Kaiser Silver HMO C	01/01/2022		SBC
Kaiser Silver HMO D (HSA Eligible)	01/01/2022		SBC
Kaiser Silver HMO E	01/01/2022		SBC
Kaiser Bronze HMO A	01/01/2022		SBC
Kaiser Bronze HMO B	01/01/2022		SBC
Kaiser Bronze HMO C (HSA Eligible)	01/01/2022		SBC
Sharp HMO
Sharp Platinum Premier HMO A	01/01/2022		SBC
Sharp Platinum Performance HMO B	01/01/2022		SBC
Sharp Platinum Premier HMO C	01/01/2022		SBC
Sharp Gold Performance HMO A	01/01/2022		SBC
Sharp Gold Premier HMO B	01/01/2022		SBC
Sharp Gold Performance HMO D	01/01/2022		SBC
Sharp Silver Premier HMO A	01/01/2022		SBC
Sharp Silver Performance HMO B	01/01/2022		SBC
Sharp Silver Premier HMO C	01/01/2022		SBC
Sharp Bronze Premier HMO A	01/01/2022		SBC
Sharp Bronze Performance HMO B (HSA Eligible)	01/01/2022		SBC
Sutter Health Plus HMO
Sutter Health Plus Platinum HMO A	01/01/2022		SBC
Sutter Health Plus Platinum HMO B	01/01/2022		SBC
Sutter Health Plus Gold HMO A	01/01/2022		SBC
Sutter Health Plus Gold HMO B	01/01/2022		SBC
Sutter Health Plus Silver HMO B	01/01/2022		SBC
Sutter Health Plus Silver HMO C (HSA Eligible)	01/01/2022		SBC
Sutter Health Plus Bronze HMO A	01/01/2022		SBC
Sutter Health Plus Bronze HMO B (HSA Eligible)	01/01/2022		SBC
UnitedHealthcare HMO
UHC Platinum SignatureValue HMO A	01/01/2022		SBC
UHC Platinum Alliance HMO C	01/01/2022		SBC
UHC Platinum SignatureValue HMO E	01/01/2022		SBC
UHC Platinum Alliance HMO G	01/01/2022		SBC
UHC Platinum Harmony HMO H	01/01/2022		SBC
UHC Platinum Harmony HMO I	01/01/2022		SBC
UHC Platinum Alliance HMO J	01/01/2022		SBC
UHC Platinum Harmony HMO K	01/01/2022		SBC
UHC Platinum SignatureValue HMO L	01/01/2022		SBC
UHC Gold SignatureValue HMO A	01/01/2022		SBC
UHC Gold Alliance HMO B	01/01/2022		SBC
UHC Gold SignatureValue HMO F	01/01/2022		SBC
UHC Gold Alliance HMO G	01/01/2022		SBC
UHC Gold SignatureValue HMO H	01/01/2022		SBC
UHC Gold Alliance HMO J	01/01/2022		SBC
UHC Gold Harmony HMO L	01/01/2022		SBC
UHC Gold Harmony HMO M	01/01/2022		SBC
UHC Gold Harmony HMO N	01/01/2022		SBC
UHC Gold Alliance HMO O	01/01/2022		SBC
UHC Gold Harmony HMO P	01/01/2022		SBC
UHC Gold SignatureValue HMO Q	01/01/2022		SBC
UHC Silver SignatureValue HMO A	01/01/2022		SBC
UHC Silver Alliance HMO E	01/01/2022		SBC
UHC Silver Harmony HMO F	01/01/2022		SBC
UHC Silver Harmony HMO G	01/01/2022		SBC
Western Health Advantage HMO
Western Health Platinum HMO A	01/01/2022		SBC
Western Health Platinum HMO B	01/01/2022		SBC
Western Health Platinum HMO C	01/01/2022		SBC
Western Health Gold HMO A	01/01/2022		SBC
Western Health Gold HMO B	01/01/2022		SBC
Western Health Gold HMO C	01/01/2022		SBC
Western Health Gold HMO D (HSA Eligible)	01/01/2022		SBC
Western Health Silver HMO A	01/01/2022		SBC
Western Health Silver HMO B	01/01/2022		SBC
Western Health Silver HMO C (HSA Eligible)	01/01/2022		SBC
Western Health Bronze HMO B	01/01/2022		SBC
Western Health Bronze HMO C (HSA Eligible)	01/01/2022		SBC
2022 Medical EPO SBCs
Anthem Blue Cross EPO
Anthem Blue Cross Silver EPO A	01/01/2022		SBC
Anthem Blue Cross Silver EPO B (HSA Eligible)	01/01/2022		SBC
Anthem Blue Cross Bronze EPO A	01/01/2022		SBC
Cigna + Oscar EPO
Cigna+Oscar Platinum LocalPlus EPO C	01/01/2022		SBC
Cigna+Oscar Platinum LocalPlus EPO D	01/01/2022		SBC
Cigna+Oscar Platinum LocalPlus EPO E	01/01/2022		SBC
Cigna+Oscar Gold LocalPlus EPO C	01/01/2022		SBC
Cigna+Oscar Gold LocalPlus EPO D	01/01/2022		SBC
Cigna+Oscar Gold LocalPlus EPO E	01/01/2022		SBC
Cigna+Oscar Silver LocalPlus EPO C	01/01/2022		SBC
Cigna+Oscar Silver LocalPlus EPO D	01/01/2022		SBC
Cigna+Oscar Silver LocalPlus EPO E (HSA Eligible)	01/01/2022		SBC
Cigna+Oscar Bronze LocalPlus EPO D	01/01/2022		SBC
Cigna+Oscar Bronze LocalPlus EPO C (HSA Eligible)	01/01/2022		SBC
Anthem Blue Cross PPO
Anthem Blue Cross Gold Advantage PPO A	01/01/2022		SBC
Anthem Blue Cross Gold Select PPO B	01/01/2022		SBC
Anthem Blue Cross Gold Select PPO C	01/01/2022		SBC
Anthem Blue Cross Gold Select PPO D	01/01/2022		SBC
Anthem Blue Cross Gold PPO E	01/01/2022		SBC
Anthem Blue Cross Silver Advantage PPO A	01/01/2022		SBC
Anthem Blue Cross Silver Select PPO B	01/01/2022		SBC
Anthem Blue Cross Silver PPO C	01/01/2022		SBC
Anthem Blue Cross Bronze PPO A (HSA Eligible)	01/01/2022		SBC
Anthem Blue Cross Bronze Select PPO B (HSA Eligible)	01/01/2022		SBC
2021 Medical Plan Benefit Summary Booklets
July - December 2021 Effective Dates
All Tiers Benefit Summaries 7.21 - 12.21 Effective Dates (updated 7.21)	08/01/2021	Summary
Platinum Benefit Summaries 7.21 - 12.21 Effective Dates (updated 7.21)	08/01/2021	Summary
Platinum/Gold Benefit Summaries 7.21 - 12.21 Effective Dates (updated 7.21)	08/01/2021	Summary
Platinum/Gold/Silver Benefit Summaries 7.21 - 12.21 Effective Dates (updated 7.21)	08/01/2021	Summary
Gold Benefit Summaries 7.21 - 12.21 Effective Dates (updated 7.21)	08/01/2021	Summary
Gold/Silver Benefit Summaries 7.21 - 12.21 Effective Dates (updated 7.21)	08/01/2021	Summary
Gold/Silver/Bronze Benefit Summaries 7.21 - 12.21 Effective Dates (updated 7.21)	08/01/2021	Summary
Silver Benefit Summaries 7.21 - 12.21 Effective Dates (updated 7.21)	08/01/2021	Summary
Silver/Bronze Benefit Summaries 7.21 - 12.21 Effective Dates (updated 7.21)	08/01/2021	Summary
Bronze Benefit Summaries 7.21 - 12.21 Effective Dates (updated 7.21)	04/01/2021	Summary
January - March 2021 Effective Dates
All Tiers Benefit Summaries 1.21 - 3.21 Effective Dates (updated 3.21)	03/01/2021	Summary
Platinum Benefit Summaries 1.21 - 3.21 Effective Dates (updated 3.21)	03/01/2021	Summary
Platinum/Gold Benefit Summaries 1.21 - 3.21 Effective Dates (updated 3.21)	03/01/2021	Summary
Platinum/Gold/Silver Benefit Summaries 1.21 - 3.21 Effective Dates (updated 3.21)	03/01/2021	Summary
Gold Benefit Summaries 1.21 - 3.21 Effective Dates (updated 3.21)	03/01/2021	Summary
Gold/Silver Benefit Summaries 1.21 - 3.21 Effective Dates (updated 3.21)	03/01/2021	Summary
Gold/Silver/Bronze Benefit Summaries 1.21 - 3.21 Effective Dates (updated 3.21)	03/01/2021	Summary
Silver Benefit Summaries 1.21 - 3.21 Effective Dates (updated 3.21)	03/01/2021	Summary
Silver/Bronze Benefit Summaries 1.21 - 3.21 Effective Dates (updated 3.21)	03/01/2021	Summary
Bronze Benefit Summaries 1.21 - 3.21 Effective Dates (updated 3.21)	03/01/2021	Summary
2021 Medical HMO SBCs
Anthem HMO
Anthem Blue Cross Platinum Select HMO A	01/01/2021		SBC
Anthem Blue Cross Gold Select HMO A	01/01/2021		SBC
Anthem Blue Cross Gold CaliforniaCare HMO B	01/01/2021		SBC
Anthem Blue Cross Silver Select HMO A	01/01/2021		SBC
Anthem Blue Cross Silver CaliforniaCare HMO B	01/01/2021		SBC
Health Net HMO
Health Net Platinum WholeCare HMO C	01/01/2021		SBC
Health Net Platinum Salud HMO D	01/01/2021		SBC
Health Net Platinum Full Network HMO E	01/01/2021		SBC
Health Net Platinum Wholecare HMO F	01/01/2021		SBC
Health Net Platinum Salud HMO G	01/01/2021		SBC
Health Net Platinum Full Network HMO H	01/01/2021		SBC
Health Net Gold WholeCare HMO A	01/01/2021		SBC
Health Net Gold WholeCare HMO B	01/01/2021		SBC
Health Net Gold WholeCare HMO C	01/01/2021		SBC
Health Net Gold Salud HMO D	01/01/2021		SBC
Health Net Gold Full Network HMO E	01/01/2021		SBC
Health Net Gold Full Network HMO F	01/01/2021		SBC
Health Net Silver WholeCare HMO A	01/01/2021		SBC
Health Net Silver CommunityCare HMO C	01/01/2021		SBC
Health Net Bronze CommunityCare HMO A	01/01/2021		SBC
Kaiser Permanente HMO
Kaiser Platinum HMO A	01/01/2021		SBC
Kaiser Platinum HMO B	01/01/2021		SBC
Kaiser Gold HMO B	01/01/2021		SBC
Kaiser Gold HMO C	01/01/2021		SBC
Kaiser Gold HMO D	01/01/2021		SBC
Kaiser Silver HMO A	01/01/2021		SBC
Kaiser Silver HMO B	01/01/2021		SBC
Kaiser Silver HMO C	01/01/2021		SBC
Kaiser Silver HMO D (HSA Eligible)	01/01/2021		SBC
Kaiser Silver HMO E	01/01/2021		SBC
Kaiser Bronze HMO A	01/01/2021		SBC
Kaiser Bronze HMO B	01/01/2021		SBC
Kaiser Bronze HMO C (HSA Eligible)	01/01/2021		SBC
Sharp HMO
Sharp Platinum Premier HMO A	01/01/2021		SBC
Sharp Platinum Performance HMO B	01/01/2021		SBC
Sharp Platinum Premier HMO C	01/01/2021		SBC
Sharp Gold Performance HMO A	01/01/2021		SBC
Sharp Gold Premier HMO B	01/01/2021		SBC
Sharp Gold Performance HMO D	01/01/2021		SBC
Sharp Silver Premier HMO A	01/01/2021		SBC
Sharp Silver Performance HMO B	01/01/2021		SBC
Sharp Silver Premier HMO C	01/01/2021		SBC
Sharp Bronze Premier HMO A	01/01/2021		SBC
Sharp Bronze Performance HMO B (HSA Eligible)	01/01/2021		SBC
Sutter Health Plus HMO
Sutter Health Plus Platinum HMO A	01/01/2021		SBC
Sutter Health Plus Platinum HMO B	01/01/2021		SBC
Sutter Health Plus Gold HMO A	01/01/2021		SBC
Sutter Health Plus Gold HMO B	01/01/2021		SBC
Sutter Health Plus Silver HMO B	01/01/2021		SBC
Sutter Health Plus Silver HMO C (HSA Eligible)	01/01/2021		SBC
Sutter Health Plus Bronze HMO A	01/01/2021		SBC
Sutter Health Plus Bronze HMO B (HSA Eligible)	01/01/2021		SBC
UnitedHealthcare HMO
UHC Platinum SignatureValue HMO A	01/01/2021		SBC
UHC Platinum Alliance HMO C	01/01/2021		SBC
UHC Platinum Advantage HMO D	01/01/2021		SBC
UHC Platinum SignatureValue HMO E	01/01/2021		SBC
UHC Platinum Advantage HMO F	01/01/2021		SBC
UHC Platinum Alliance HMO G	01/01/2021		SBC
UHC Platinum Harmony HMO H (New for 7/1/2021)	07/01/2021		SBC
UHC Platinum Harmony HMO I (New for 7/1/2021)	07/01/2021		SBC
UHC Gold SignatureValue HMO A	01/01/2021		SBC
UHC Gold Alliance HMO B	01/01/2021		SBC
UHC Gold Advantage HMO E	01/01/2021		SBC
UHC Gold SignatureValue HMO F	01/01/2021		SBC
UHC Gold Alliance HMO G	01/01/2021		SBC
UHC Gold SignatureValue HMO H	01/01/2021		SBC
UHC Gold Advantage HMO I	01/01/2021		SBC
UHC Gold Alliance HMO J	01/01/2021		SBC
UHC Gold Advantage HMO K	01/01/2021		SBC
UHC Gold Harmony HMO L (New for 7/1/2021)	07/01/2021		SBC
UHC Gold Harmony HMO M (New for 7/1/2021)	07/01/2021		SBC
UHC Gold Harmony HMO N (New for 7/1/2021)	07/01/2021		SBC
UHC Silver SignatureValue HMO A	01/01/2021		SBC
UHC Silver Advantage HMO B	01/01/2021		SBC
UHC Silver Alliance HMO E	01/01/2021		SBC
UHC Silver Harmony HMO F (New for 7/1/2021)	07/01/2021		SBC
UHC Silver Harmony HMO G (New for 7/1/2021)	08/01/2021		SBC
Western Health Advantage HMO	01/01/2021		SBC
Western Health Platinum HMO C	01/01/2021		SBC
Western Health Gold HMO A	01/01/2021		SBC
Western Health Gold HMO B	03/01/2021		SBC
Western Health Gold HMO C	01/01/2021		SBC
Western Health Gold HMO D (HSA Eligible)	01/01/2021		SBC
Western Health Silver HMO A	01/01/2021		SBC
Western Health Silver HMO B	01/01/2021		SBC
Western Health Silver HMO C (HSA Eligible)	01/01/2021		SBC
Western Health Bronze HMO B	01/01/2021		SBC
Western Health Bronze HMO C (HSA Eligible)	01/01/2021		SBC
2021 Medical EPO SBCs
Anthem Blue Cross EPO
Anthem Blue Cross Silver EPO A	01/01/2021		SBC
Anthem Blue Cross Silver EPO B (HSA Eligible)	01/01/2021		SBC
Anthem Blue Cross Bronze EPO A	01/01/2021		SBC
Cigna + Oscar EPO
Cigna+Oscar Platinum LocalPlus EPO A (New for 7/1/2021)	07/01/2021		SBC
Cigna+Oscar Platinum LocalPlus EPO B (New for 7/1/2021)	07/01/2021		SBC
Cigna+Oscar Gold LocalPlus EPO A (New for 7/1/2021)	07/01/2021		SBC
Western Health Bronze HMO B	01/01/2021		SBC
Western Health Bronze HMO C (HSA Eligible)	01/01/2021		SBC
2021 Medical EPO SBCs
Anthem Blue Cross EPO
Anthem Blue Cross Silver EPO A	01/01/2021		SBC
Anthem Blue Cross Silver EPO B (HSA Eligible)	01/01/2021		SBC
Anthem Blue Cross Bronze EPO A	01/01/2021		SBC
Cigna + Oscar EPO
Cigna+Oscar Platinum LocalPlus EPO A (New for 7/1/2021)	07/01/2021		SBC
Cigna+Oscar Platinum LocalPlus EPO B (New for 7/1/2021)	01/01/2021		SBC
Oscar Gold EPO A	01/01/2021		SBC
Oscar Gold EPO B	01/01/2021		SBC
Oscar Gold EPO C	01/01/2021		SBC
Oscar Gold EPO D	01/01/2021		SBC
Oscar Silver EPO A (HSA Eligible)	01/01/2021		SBC
Oscar Silver EPO B	01/01/2021		SBC
Oscar Silver EPO C	01/01/2021		SBC
Oscar Silver EPO D	01/01/2021		SBC
Oscar Bronze EPO A (HSA Eligible)	01/01/2021		SBC
Oscar Bronze EPO B	01/01/2021		SBC
Oscar Bronze EPO C	01/01/2021		SBC
2021 Medical PPO SBCs
Anthem Blue Cross PPO
Anthem Blue Cross Gold Advantage PPO A	01/01/2021		SBC
Anthem Blue Cross Gold Select PPO B	01/01/2021		SBC
Anthem Blue Cross Gold Select PPO C	01/01/2021		SBC
Anthem Blue Cross Gold Select PPO D	01/01/2021		SBC
Anthem Blue Cross Gold PPO E	01/01/2021		SBC
Anthem Blue Cross Silver Advantage PPO A	01/01/2021		SBC
Anthem Blue Cross Silver Select PPO B	01/01/2021		SBC
Anthem Blue Cross Silver PPO C	01/01/2021		SBC
Anthem Blue Cross Bronze PPO A (HSA Eligible)	01/01/2021		SBC
Anthem Blue Cross Bronze Select PPO B (HSA Eligible)	01/01/2021		SBC

Form Name	Effective Date	Download Form
General Information
CaliforniaChoice Fast Facts Brochure 1.22	01/01/2022	Download
CaliforniaChoice Underwriting Guidelines 3.22	03/01/2022	Download
Cal Perks Flyer	10/01/2023	Download
Choice Administrators Agent Agreement	02/01/2023	Download
Choice Administrators Amendment Agent Agreement	02/01/2023	Download
Choice Administrators Broker License Form	02/01/2023	Download
Choice Administrators Direct Deposit Authorization	02/01/2023	Download
IRS W-9 Request for Taxpayer Identification Number & Certification	01/01/2022	Download
Mobile App Flyer	04/01/2023	Download
Payroll & HRIS Solutions via CaliforniaChoice	01/01/2022	Download
Premium Only Plan Flyer	01/01/2022	Download
Program Highlights Flyer	01/01/2022	Download
Smart Decision Technology Overview for Brokers	01/01/2022	Download
Smart Decision Technology Overview for Employers	01/01/2022	Download
Smart Decision Technology - Automated Choice Profiler	01/01/2022	Download
Smart Decision Technology - Online Enrollment	01/01/2022	Download
Smart Decision Technology - Online Rx Search	01/01/2022	Download
Website Features Flyer - Brokers	01/01/2022	Download
Website Features Flyer - Employers	01/01/2022	Download
Website Features Flyer - Employees	01/01/2022	Download
Medical
CaliforniaChoice Member Enrollment Guide 7.23 - 12.23 Effective Dates	07/01/2023	Download
CaliforniaChoice Member Enrollment Guide 4.23 - 6.23 Effective Dates	04/01/2023	Download
CaliforniaChoice Member Enrollment Guide 1.23 - 3.23 Effective Dates	01/01/2023	Download
CaliforniaChoice Member Enrollment Guide 7.22 - 12.22 Effective Dates	07/01/2022	Download
CaliforniaChoice Summary of Changes for Groups Renewing 1.24 - 3.24 Effective Dates	01/01/2024	Download
CaliforniaChoice Summary of Changes for Groups Renewing 7.23 - 12.23 Effective Dates	07/01/2023	Download
CaliforniaChoice Summary of Changes for Groups Renewing 4.23 - 6.23 Effective Dates	04/01/2023	Download
CaliforniaChoice Summary of Changes for Groups Renewing 3.23 - 3.23 Effective Dates	03/01/2023	Download
CaliforniaChoice Summary of Changes for Groups Renewing 1.23 - 2.23 Effective Dates	01/01/2023	Download
HSA Guide Brochure	01/01/2023	Download
Infertility Benefit Grid 3.22 Effective Dates	03/01/2022	Download
Medicare Part D Credibility 1.22 Effective Dates	01/01/2022	Download
Network Availability by Carrier & Plan Summary 3.22	03/01/2022	Download
Online Provider Search Instructions	04/01/2023	Download
Provider Network Definitions 7.23 - 12.23 Effective Dates	07/01/2023	Download
Provider Network Definitions 4.23 - 6.23 Effective Dates	04/01/2023	Download
Provider Network Definitions 1.23 - 3.23 Effective Dates	01/01/2023	Download
SBC-EOC Flyer	01/01/2022	Download
Ancillary
Employer Guide to Optional Benefits 7.22 - 12.23 Effective Dates	01/01/2023	Download
Chiropractic & Acupuncture Benefits Flyer 4.23 - 12.23 Effective Dates	04/01/2023	Download
Landmark Acupuncture Directory 4.23	04/01/2023	Download
Landmark Chiropractic Directory 4.23	04/01/2023	Download
Dental Benefits Flyer 4.23 - 12.23 Effective Dates	04/01/2023	Download
Dentegra Smile Club Program Flyer 7.22	01/01/2023	Download
Hearing Value Added Benefit Flyer 4.23 - 12.23 Effective Dates	04/01/2023	Download
Life Insurance Benefits Flyer 4.23 - 12.23 Effective Dates	04/01/2023	Download
Vision Benefits Flyer 4.22 - 12.23 Effective Dates	04/01/2023	Download
Vision One Eyecare Discount Program	01/01/2023	Download

Video Name	Watch Video
Intro to CaliforniaChoice	Watch Video Intro to CaliforniaChoice
CaliforniaChoice What is Defined Contribution?	Watch Video CaliforniaChoice What is Defined Contribution?
CaliforniaChoice Health Insurance Plans	Watch Video CaliforniaChoice Health Insurance Plans
CaliforniaChoice Ease of Administration	Watch Video CaliforniaChoice Ease of Administration
CaliforniaChoice Additional Plans and Perks	Watch Video CaliforniaChoice Additional Plans and Perks
CaliforniaChoice Working with Health Insurance Brokers	Watch Video CaliforniaChoice Working with Health Insurance Brokers

Form Name	Effective Date	Download Form
Rate Guide Summary [effective 1/1/2024 to 3/1/2024]	01/01/2024	Download
Rate Guide Summary [effective 10/1/2023 to 12/1/2023]	10/01/2023	Download
Rate Guide Summary [effective 7/1/2023 to 9/1/2023]	07/01/2023	Download
Rate Guide Summary [effective 4/1/2023 to 6/1/2023]	04/01/2023	Download
Rate Guide Summary [effective 1/1/2023 to 3/1/2023]	01/01/2023	Download

CaliforniaChoice

Provider Finder