| Form Name | Effective Date | Download Form |
|---|---|---|
|
New Group Submission |
||
|
New Group Submission Checklist 1.21 |
01/01/2021 | Download |
|
Employer Application 1.23 |
01/01/2023 | Download |
|
Employer Application 1.22 |
01/01/2022 | Download |
|
ACH Authorization Form |
12/01/2022 | Download |
|
Corporate Officer/Proprietor/Partner Verification Statement |
12/01/2022 | Download |
|
Administration |
||
|
Business Administrative Guide |
01/01/2021 | 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 |
|
Employee Waiver Form |
12/01/2022 | Download |
|
Deductible Credit Form |
12/01/2022 | Download |
|
Disabled Dependent Form |
12/01/2022 | Download |
|
Express Scripts Home Delivery Order Form |
01/01/2021 | Download |
|
Claim Forms |
||
|
HIPAA Authorization to Disclose PHI Form |
12/01/2022 | Download |
|
Member Medical Claim Form |
04/01/2021 | Download |
|
Prescription Reimbursement Direct Claim Form |
04/01/2021 | Download |
| Form Name | Effective Date | Download Form | |
|---|---|---|---|
|
2023 Medical PPO |
|||
|
LocalPlus Network |
|||
|
LocalPlus Platinum $0/$10 |
01/01/2023 | Summary | SBC |
|
LocalPlus Platinum $0/$10 INF |
01/01/2023 | Summary | SBC |
|
LocalPlus Platinum $0/$20 |
01/01/2023 | Summary | SBC |
|
LocalPlus Platinum $0/$20 INF |
01/01/2023 | Summary | SBC |
|
LocalPlus Platinum $250 |
01/01/2023 | Summary | SBC |
|
LocalPlus Platinum $250 INF |
01/01/2023 | Summary | SBC |
|
LocalPlus Platinum $500 |
01/01/2023 | Summary | SBC |
|
LocalPlus Platinum $500 INF |
01/01/2023 | Summary | SBC |
|
LocalPlus Gold $0 |
01/01/2023 | Summary | SBC |
|
LocalPlus Gold $0 INF |
01/01/2023 | Summary | SBC |
|
LocalPlus Gold $250 |
01/01/2023 | Summary | SBC |
|
LocalPlus Gold $250 INF |
01/01/2023 | Summary | SBC |
|
LocalPlus Gold $500 |
01/01/2023 | Summary | SBC |
|
LocalPlus Gold $500 INF |
01/01/2023 | Summary | SBC |
|
LocalPlus Gold $750 |
01/01/2023 | Summary | SBC |
|
LocalPlus Gold $750 INF |
01/01/2023 | Summary | SBC |
|
LocalPlus Gold $1350 |
01/01/2023 | Summary | SBC |
|
LocalPlus Gold $1350 INF |
01/01/2023 | Summary | SBC |
|
LocalPlus Silver $0 |
01/01/2023 | Summary | SBC |
|
LocalPlus Silver $0 INF |
01/01/2023 | Summary | SBC |
|
LocalPlus Silver $1950 |
01/01/2023 | Summary | SBC |
|
LocalPlus Silver $1950 INF |
01/01/2023 | Summary | SBC |
|
LocalPlus Silver $2500 |
01/01/2023 | Summary | SBC |
|
LocalPlus Silver $2500 INF |
01/01/2023 | Summary | SBC |
|
LocalPlus Silver $2600 |
01/01/2023 | Summary | SBC |
|
LocalPlus Silver $2600 INF |
01/01/2023 | Summary | SBC |
|
LocalPlus Silver $3000 HSA |
01/01/2023 | Summary | SBC |
|
LocalPlus Silver $3000 HSA INF |
01/01/2023 | Summary | SBC |
|
LocalPlus Bronze $1000 |
01/01/2023 | Summary | SBC |
|
LocalPlus Bronze $1000 INF |
01/01/2023 | Summary | SBC |
|
LocalPlus Bronze $3000 |
01/01/2023 | Summary | SBC |
|
LocalPlus Bronze $3000 INF |
01/01/2023 | Summary | SBC |
|
LocalPlus Bronze $6000 |
01/01/2023 | Summary | SBC |
|
LocalPlus Bronze $6000 INF |
01/01/2023 | Summary | SBC |
|
LocalPlus Bronze $6300 |
01/01/2023 | Summary | SBC |
|
LocalPlus Bronze $6300 INF |
01/01/2023 | Summary | SBC |
|
LocalPlus Bronze $7250 |
01/01/2023 | Summary | SBC |
|
LocalPlus Bronze $7250 INF |
01/01/2023 | Summary | SBC |
|
LocalPlus Bronze $5750 HSA |
01/01/2023 | Summary | SBC |
|
LocalPlus Bronze $5750 HSA INF |
01/01/2023 | Summary | SBC |
|
Open Access Plus Network |
|||
|
Open Access Plus Platinum $0/$10 |
01/01/2023 | Summary | SBC |
|
Open Access Plus Platinum $0/$10 INF |
01/01/2023 | Summary | SBC |
|
Open Access Plus Platinum $0/$20 |
01/01/2023 | Summary | SBC |
|
Open Access Plus Platinum $0/$20 INF |
01/01/2023 | Summary | SBC |
|
Open Access Plus Platinum $250 |
01/01/2023 | Summary | SBC |
|
Open Access Plus Platinum $250 INF |
01/01/2023 | Summary | SBC |
|
Open Access Plus Platinum $500 |
01/01/2023 | Summary | SBC |
|
Open Access Plus Platinum $500 INF |
01/01/2023 | Summary | SBC |
|
Open Access Plus Gold $0 |
01/01/2023 | Summary | SBC |
|
Open Access Plus Gold $0 INF |
01/01/2023 | Summary | SBC |
|
Open Access Plus Gold $250 |
01/01/2023 | Summary | SBC |
|
Open Access Plus Gold $250 INF |
01/01/2023 | Summary | SBC |
|
Open Access Plus Gold $500 |
01/01/2023 | Summary | SBC |
|
Open Access Plus Gold $500 INF |
01/01/2023 | Summary | SBC |
|
Open Access Plus Gold $750 |
01/01/2023 | Summary | SBC |
|
Open Access Plus Gold $750 INF |
01/01/2023 | Summary | SBC |
|
Open Access Plus Gold $1350 |
01/01/2023 | Summary | SBC |
|
Open Access Plus Gold $1350 INF |
01/01/2023 | Summary | SBC |
|
Open Access Plus Silver $0 |
01/01/2023 | Summary | SBC |
|
Open Access Plus Silver $0 INF |
01/01/2023 | Summary | SBC |
|
Open Access Plus Silver $1950 |
01/01/2023 | Summary | SBC |
|
Open Access Plus Silver $1950 INF |
01/01/2023 | Summary | SBC |
|
Open Access Plus Silver $2500 |
01/01/2023 | Summary | SBC |
|
Open Access Plus Silver $2500 INF |
01/01/2023 | Summary | SBC |
|
Open Access Plus Silver $2600 |
01/01/2023 | Summary | SBC |
|
Open Access Plus Silver $2600 INF |
01/01/2023 | Summary | SBC |
|
Open Access Plus Silver $3000 HSA |
01/01/2023 | Summary | SBC |
|
Open Access Plus Silver $3000 HSA INF |
01/01/2023 | Summary | SBC |
|
Open Access Plus Bronze $1000 |
01/01/2023 | Summary | SBC |
|
Open Access Plus Bronze $1000 INF |
01/01/2023 | Summary | SBC |
|
Open Access Plus Bronze $3000 |
01/01/2023 | Summary | SBC |
|
Open Access Plus Bronze $3000 INF |
01/01/2023 | Summary | SBC |
|
Open Access Plus Bronze $6000 |
01/01/2023 | Summary | SBC |
|
Open Access Plus Bronze $6000 INF |
01/01/2023 | Summary | SBC |
|
Open Access Plus Bronze $6300 |
01/01/2023 | Summary | SBC |
|
Open Access Plus Bronze $6300 INF |
01/01/2023 | Summary | SBC |
|
Open Access Plus Bronze $7250 |
01/01/2023 | Summary | SBC |
|
Open Access Plus Bronze $7250 INF |
01/01/2023 | Summary | SBC |
|
Open Access Plus Bronze $5750 HSA |
01/01/2023 | Summary | SBC |
|
Open Access Plus Bronze $5750 HSA INF |
01/01/2023 | Summary | SBC |
|
2022 Medical EPO |
|||
|
LocalPlus Network |
|||
|
LocalPlus Platinum $0/$10 |
01/01/2022 | Summary | SBC |
|
LocalPlus Platinum $0/$10 INF |
01/01/2022 | Summary | SBC |
|
LocalPlus Platinum $0/$20 |
01/01/2022 | Summary | SBC |
|
LocalPlus Platinum $0/$20 INF |
01/01/2022 | Summary | SBC |
|
LocalPlus Platinum $250 |
01/01/2022 | Summary | SBC |
|
LocalPlus Platinum $250 INF |
01/01/2022 | Summary | SBC |
|
LocalPlus Platinum $500 |
01/01/2022 | Summary | SBC |
|
LocalPlus Platinum $500 INF |
01/01/2022 | Summary | SBC |
|
LocalPlus Gold $0 |
01/01/2022 | Summary | SBC |
|
LocalPlus Gold $0 INF |
01/01/2022 | Summary | SBC |
|
LocalPlus Gold $250 |
01/01/2022 | Summary | SBC |
|
LocalPlus Gold $250 INF |
01/01/2022 | Summary | SBC |
|
LocalPlus Gold $500 |
01/01/2022 | Summary | SBC |
|
LocalPlus Gold $500 INF |
01/01/2022 | Summary | SBC |
|
LocalPlus Gold $750 |
01/01/2022 | Summary | SBC |
|
LocalPlus Gold $750 INF |
01/01/2022 | Summary | SBC |
|
LocalPlus Gold $1350 |
01/01/2022 | Summary | SBC |
|
LocalPlus Gold $1350 INF |
01/01/2022 | Summary | SBC |
|
LocalPlus Silver $0 |
01/01/2022 | Summary | SBC |
|
LocalPlus Silver $0 INF |
01/01/2022 | Summary | SBC |
|
LocalPlus Silver $1950 |
01/01/2022 | Summary | SBC |
|
LocalPlus Silver $1950 INF |
01/01/2022 | Summary | SBC |
|
LocalPlus Silver $2250 |
01/01/2022 | Summary | SBC |
|
LocalPlus Silver $2250 INF |
01/01/2022 | Summary | SBC |
|
LocalPlus Silver $2600 |
01/01/2022 | Summary | SBC |
|
LocalPlus Silver $2600 INF |
01/01/2022 | Summary | SBC |
|
LocalPlus Silver $2500 HSA |
01/01/2022 | Summary | SBC |
|
LocalPlus Silver $2500 HSA INF |
01/01/2022 | Summary | SBC |
|
LocalPlus Bronze $1000 |
01/01/2022 | Summary | SBC |
|
LocalPlus Bronze $1000 INF |
01/01/2022 | Summary | SBC |
|
LocalPlus Bronze $6000 |
01/01/2022 | Summary | SBC |
|
LocalPlus Bronze $6000 INF |
01/01/2022 | Summary | SBC |
|
LocalPlus Bronze $6300 |
01/01/2022 | Summary | SBC |
|
LocalPlus Bronze $6300 INF |
01/01/2022 | Summary | SBC |
|
LocalPlus Bronze $5750 HSA |
01/01/2022 | Summary | SBC |
|
LocalPlus Bronze $5750 HSA INF |
01/01/2022 | Summary | SBC |
|
Open Access Plus Network |
|||
|
Open Access Plus Platinum $0/$10 |
01/01/2022 | Summary | SBC |
|
Open Access Plus Platinum $0/$10 INF |
01/01/2022 | Summary | SBC |
|
Open Access Plus Platinum $0/$20 |
01/01/2022 | Summary | SBC |
|
Open Access Plus Platinum $0/$20 INF |
01/01/2022 | Summary | SBC |
|
Open Access Plus Platinum $250 |
01/01/2022 | Summary | SBC |
|
Open Access Plus Platinum $250 INF |
01/01/2022 | Summary | SBC |
|
Open Access Plus Platinum $500 |
01/01/2022 | Summary | SBC |
|
Open Access Plus Platinum $500 INF |
01/01/2022 | Summary | SBC |
|
Open Access Plus Gold $0 |
01/01/2022 | Summary | SBC |
|
Open Access Plus Gold $0 INF |
01/01/2022 | Summary | SBC |
|
Open Access Plus Gold $250 |
01/01/2022 | Summary | SBC |
|
Open Access Plus Gold $250 INF |
01/01/2022 | Summary | SBC |
|
Open Access Plus Gold $500 |
01/01/2022 | Summary | SBC |
|
Open Access Plus Gold $500 INF |
01/01/2022 | Summary | SBC |
|
Open Access Plus Gold $750 |
01/01/2022 | Summary | SBC |
|
Open Access Plus Gold $750 INF |
01/01/2022 | Summary | SBC |
|
Open Access Plus Gold $1350 |
01/01/2022 | Summary | SBC |
|
Open Access Plus Gold $1350 INF |
01/01/2022 | Summary | SBC |
|
Open Access Plus Silver $0 |
01/01/2022 | Summary | SBC |
|
Open Access Plus Silver $0 INF |
01/01/2022 | Summary | SBC |
|
Open Access Plus Silver $1950 |
01/01/2022 | Summary | SBC |
|
Open Access Plus Silver $1950 INF |
01/01/2022 | Summary | SBC |
|
Open Access Plus Silver $2250 |
01/01/2022 | Summary | SBC |
|
Open Access Plus Silver $2250 INF |
01/01/2022 | Summary | SBC |
|
Open Access Plus Silver $2600 |
01/01/2022 | Summary | SBC |
|
Open Access Plus Silver $2600 INF |
01/01/2022 | Summary | SBC |
|
Open Access Plus Silver $2500 HSA |
01/01/2022 | Summary | SBC |
|
Open Access Plus Silver $2500 HSA INF |
01/01/2022 | Summary | SBC |
|
Open Access Plus Bronze $1000 |
01/01/2022 | Summary | SBC |
|
Open Access Plus Bronze $1000 INF |
01/01/2022 | Summary | SBC |
|
Open Access Plus Bronze $6000 |
01/01/2022 | Summary | SBC |
|
Open Access Plus Bronze $6000 INF |
01/01/2022 | Summary | SBC |
|
Open Access Plus Bronze $6300 |
01/01/2022 | Summary | SBC |
|
Open Access Plus Bronze $6300 INF |
01/01/2022 | Summary | SBC |
|
Open Access Plus Bronze $5750 HSA |
01/01/2022 | Summary | SBC |
|
Open Access Plus Bronze $5750 HSA INF |
01/01/2022 | Summary | SBC |
|
2021 Medical EPO |
|||
|
LocalPlus Network |
|||
|
LocalPlus Platinum 0 Option 1 |
01/01/2021 | Summary | SBC |
|
LocalPlus Platinum 0 Option 1 INF |
01/01/2021 | Summary | SBC |
|
LocalPlus Platinum 0 Option 2 |
01/01/2021 | Summary | SBC |
|
LocalPlus Platinum 0 Option 2 INF |
01/01/2021 | Summary | SBC |
|
LocalPlus Platinum 250 |
01/01/2021 | Summary | SBC |
|
LocalPlus Platinum 250 INF |
01/01/2021 | Summary | SBC |
|
LocalPlus Platinum 500 |
01/01/2021 | Summary | SBC |
|
LocalPlus Platinum 500 INF |
01/01/2021 | Summary | SBC |
|
LocalPlus Gold 0 |
01/01/2021 | Summary | SBC |
|
LocalPlus Gold 0 INF |
01/01/2021 | Summary | SBC |
|
LocalPlus Gold 250 |
01/01/2021 | Summary | SBC |
|
LocalPlus Gold 250 INF |
01/01/2021 | Summary | SBC |
|
LocalPlus Gold 750 |
01/01/2021 | Summary | SBC |
|
LocalPlus Gold 750 INF |
01/01/2021 | Summary | SBC |
|
LocalPlus Gold 1200 |
01/01/2021 | Summary | SBC |
|
LocalPlus Gold 1200 INF |
01/01/2021 | Summary | SBC |
|
LocalPlus Silver 1700 |
01/01/2021 | Summary | SBC |
|
LocalPlus Silver 1700 INF |
01/01/2021 | Summary | SBC |
|
LocalPlus Silver 2000 |
01/01/2021 | Summary | SBC |
|
LocalPlus Silver 2000 INF |
01/01/2021 | Summary | SBC |
|
LocalPlus Silver 2250 Option 1 |
01/01/2021 | Summary | SBC |
|
LocalPlus Silver 2250 Option 1 INF |
01/01/2021 | Summary | SBC |
|
LocalPlus Silver 2250 Option 2 |
01/01/2021 | Summary | SBC |
|
LocalPlus Silver 2250 Option 2 INF |
01/01/2021 | Summary | SBC |
|
LocalPlus Bronze 6000 |
01/01/2021 | Summary | SBC |
|
LocalPlus Bronze 6000 INF |
01/01/2021 | Summary | SBC |
|
LocalPlus Bronze 6300 |
01/01/2021 | Summary | SBC |
|
LocalPlus Bronze 6300 INF |
01/01/2021 | Summary | SBC |
|
LocalPlus Bronze 5500 HSA |
01/01/2021 | Summary | SBC |
|
LocalPlus Bronze 5500 HSA INF |
01/01/2021 | Summary | SBC |
|
LocalPlus Bronze 6500 HSA |
01/01/2021 | Summary | SBC |
|
LocalPlus Bronze 6500 HSA INF |
01/01/2021 | Summary | SBC |
|
Open Access Plus Network |
|||
|
Open Access Plus Platinum 0 Option 1 |
01/01/2021 | Summary | SBC |
|
Open Access Plus Platinum 0 Option 1 INF |
01/01/2021 | Summary | SBC |
|
Open Access Plus Platinum 0 Option 2 |
01/01/2021 | Summary | SBC |
|
Open Access Plus Platinum 0 Option 2 INF |
01/01/2021 | Summary | SBC |
|
Open Access Plus Platinum 250 |
01/01/2021 | Summary | SBC |
|
Open Access Plus Platinum 250 INF |
01/01/2021 | Summary | SBC |
|
Open Access Plus Platinum 500 |
01/01/2021 | Summary | SBC |
|
Open Access Plus Platinum 500 INF |
01/01/2021 | Summary | SBC |
|
Open Access Plus Gold 0 |
01/01/2021 | Summary | SBC |
|
Open Access Plus Gold 0 INF |
01/01/2021 | Summary | SBC |
|
Open Access Plus Gold 250 |
01/01/2021 | Summary | SBC |
|
Open Access Plus Gold 250 INF |
01/01/2021 | Summary | SBC |
|
Open Access Plus Gold 750 |
01/01/2021 | Summary | SBC |
|
Open Access Plus Gold 750 INF |
01/01/2021 | Summary | SBC |
|
Open Access Plus Gold 1200 |
01/01/2021 | Summary | SBC |
|
Open Access Plus Gold 1200 INF |
01/01/2021 | Summary | SBC |
|
Open Access Plus Silver 1700 |
01/01/2021 | Summary | SBC |
|
Open Access Plus Silver 1700 INF |
01/01/2021 | Summary | SBC |
|
Open Access Plus Silver 2000 |
01/01/2021 | Summary | SBC |
|
Open Access Plus Silver 2000 INF |
01/01/2021 | Summary | SBC |
|
Open Access Plus Silver 2250 Option 1 |
01/01/2021 | Summary | SBC |
|
Open Access Plus Silver 2250 Option 1 INF |
01/01/2021 | Summary | SBC |
|
Open Access Plus Silver 2250 Option 2 |
01/01/2021 | Summary | SBC |
|
Open Access Plus Silver 2250 Option 2 INF |
01/01/2021 | Summary | SBC |
|
Open Access Plus Bronze 6000 |
01/01/2021 | Summary | SBC |
|
Open Access Plus Bronze 6000 INF |
01/01/2021 | Summary | SBC |
|
Open Access Plus Bronze 6300 |
01/01/2021 | Summary | SBC |
|
Open Access Plus Bronze 6300 INF |
01/01/2021 | Summary | SBC |
|
Open Access Plus Bronze 5500 HSA |
01/01/2021 | Summary | SBC |
|
Open Access Plus Bronze 5500 HSA INF |
01/01/2021 | Summary | SBC |
|
Open Access Plus Bronze 6500 HSA |
01/01/2021 | Summary | SBC |
|
Open Access Plus Bronze 6500 HSA INF |
01/01/2021 | Summary | SBC |
| Form Name | Effective Date | Download Form |
|---|---|---|
|
General Information |
||
|
Broker Appointment Guide |
03/01/2021 | Download |
|
Broker Client Onboarding Guide |
01/01/2021 | Download |
|
Care Team Customer Service Flyer |
04/01/2021 | Download |
|
Doctor on Call Flyer |
04/01/2021 | Download |
|
What is an Exclusive Provider Organization (EPO) |
04/01/2021 | Download |
|
Helpful Information & Resources Flyer |
01/01/2022 | Download |
|
Hi, we're Oscar Flyer |
01/01/2021 | Download |
|
Introducing Cigna + Oscar Flyer |
03/01/2021 | Download |
|
Online and Mobile Tools |
01/01/2021 | Download |
|
Dual Network Overview - Bay Area 1.23 |
01/01/2023 | Download |
|
Dual Network Overview - Central Coast 1.23 |
01/01/2023 | Download |
|
Dual Network Overview - Los Angeles & Orange County 1.23 |
01/01/2023 | Download |
|
Dual Network Overview - San Diego County 1.23 |
01/01/2023 | Download |
|
Dual Network Overview - Inland Empire 1.23 |
01/01/2023 | Download |
|
Post-enrollment Timeline |
01/01/2021 | Download |
|
Provider Education FAQ |
12/01/2022 | Download |
|
Step Tracking Flyer |
01/01/2021 | Download |
|
Underwriting Guide 10.21 |
12/01/2022 | Download |
|
What's Included in Your Plan for $0 |
01/01/2021 | Download |
|
Medical |
||
|
Small Group Plan Grid 1.23 |
01/01/2023 | Download |
|
Small Group Plan Grid 1.22 |
01/01/2022 | Download |
|
Express Scripts Prescription Drug Formulary List 1.23 |
01/01/2023 | Download |
|
Express Scripts Prescription Drug Formulary List (with Infertility) 1.23 |
01/01/2023 | Download |
|
Express Scripts Prescription Drug Formulary List 1.22 |
01/01/2022 | Download |
|
Preventive Care Brochure |
01/01/2021 | Download |
| Form Name | Effective Date | Download Form |
|---|---|---|
|
Northern California Small Group Rate Guide [effective 1/1/2023] |
01/01/2023 | Download |
|
Southern California Small Group Rate Guide [effective 1/1/2023] |
01/01/2023 | Download |
|
Northern California Small Group Rate Guide [effective 1/1/2022] |
01/01/2022 | Download |
|
Southern California Small Group Rate Guide [effective 1/1/2022] |
01/01/2022 | Download |
