| Form Name | Effective Date | Download Form |
|---|---|---|
|
New Group Submissions |
||
|
New Business Submission Checklist - Small Group 4.24 |
04/01/2024 | Download |
|
Employer Application - Small Group 1.24 |
01/01/2024 | Download |
|
Premium Payment Options |
04/01/2024 | Download |
|
Sole Proprietor, Partner or Corporate Officer Eligibility Statement |
04/01/2024 | Download |
|
New Employee Verification Form |
04/01/2024 | Download |
|
New Business Submission Checklist - Large Group 1.24 |
01/01/2024 | Download |
|
Employer Application - Large Group 1.24 |
01/01/2024 | Download |
|
Administration |
||
|
Employer Administrative Guide |
01/01/2022 | Download |
|
Termination Form |
01/01/2024 | Download |
| Form Name | Effective Date | Download Form |
|---|---|---|
|
Enrollment and Change Forms |
||
|
Employee Enrollment and Change Form - Small Group 4.24 |
04/01/2024 | Download |
|
Employee Enrollment and Change Form - Small Group 1.24 |
01/01/2024 | Download |
|
Employee Enrollment and Change Form - Large Group 1.24 |
01/01/2024 | Download |
|
Declination of Coverage Form |
04/01/2024 | Download |
|
Continuity of Care Services Request Form |
04/01/2024 | Download |
|
Disabled Dependent Certification Form |
01/01/2024 | Download |
|
Claim Forms |
||
|
Authorization for the Use or Disclosure of Health Information |
01/01/2022 | Download |
|
Member Claim Form |
01/01/2022 | Download |
|
Mail Order Rx Delivery Form |
01/01/2022 | Download |
| Form Name | Effective Date | Download Form | |
|---|---|---|---|
|
2024 Small Group Standard Medical HMO |
|||
|
Platinum MS78 HMO |
01/01/2024 | Summary | SBC |
|
Platinum MS90 HMO |
01/01/2024 | Summary | SBC |
|
Gold MS72 HMO |
01/01/2024 | Summary | SBC |
|
Gold MS87 HMO |
01/01/2024 | Summary | SBC |
|
Gold MS93 HMO |
01/01/2024 | Summary | SBC |
|
Gold SD12 HDHP HMO |
01/01/2024 | Summary | SBC |
|
Silver MS94 HMO |
01/01/2024 | Summary | SBC |
|
Silver SD11 HDHP HMO |
01/01/2024 | Summary | SBC |
|
Bronze MS96 HMO |
01/01/2024 | Summary | SBC |
|
Bronze SD03 HDHP HMO |
01/01/2024 | Summary | SBC |
|
2024 Small Group Plus Medical HMO |
|||
|
Platinum MP78 Plus HMO |
01/01/2024 | Summary | SBC |
|
Platinum MP90 Plus HMO |
01/01/2024 | Summary | SBC |
|
Gold MP72 Plus HMO |
01/01/2024 | Summary | SBC |
|
Gold MP87 Plus HMO |
01/01/2024 | Summary | SBC |
|
Gold MP93 Plus HMO |
01/01/2024 | Summary | SBC |
|
Gold SP12 Plus HDHP HMO |
01/01/2024 | Summary | SBC |
|
Silver MP94 Plus HMO |
01/01/2024 | Summary | SBC |
|
Silver SP11 Plus HDHP HMO |
01/01/2024 | Summary | SBC |
|
Bronze MP96 Plus HMO |
01/01/2024 | Summary | SBC |
|
Bronze SP03 Plus HDHP HMO |
01/01/2024 | Summary | SBC |
|
2024 Large Group Medical HMO |
|||
|
Summit ML78 HMO |
01/01/2024 | Summary | SBC |
|
Summit ML79 HMO |
01/01/2024 | Summary | SBC |
|
Summit ML80 HMO |
01/01/2024 | Summary | SBC |
|
Summit ML81 HMO |
01/01/2024 | Summary | SBC |
|
Summit ML82 HMO |
01/01/2024 | Summary | SBC |
|
Summit ML83 HMO |
01/01/2024 | Summary | SBC |
|
Summit ML84 HMO |
01/01/2024 | Summary | SBC |
|
Peak ML85 HMO |
01/01/2024 | Summary | SBC |
|
Peak ML86 HMO |
01/01/2024 | Summary | SBC |
|
Peak ML87 HMO |
01/01/2024 | Summary | SBC |
|
Peak ML88 HMO |
01/01/2024 | Summary | SBC |
|
Peak ML89 HMO |
01/01/2024 | Summary | SBC |
|
Peak ML90 HMO |
01/01/2024 | Summary | SBC |
|
Peak ML91 HMO |
01/01/2024 | Summary | SBC |
|
Ridge ML92 HMO |
01/01/2024 | Summary | SBC |
|
Ridge ML93 HMO |
01/01/2024 | Summary | SBC |
|
Ridge ML94 HMO |
01/01/2024 | Summary | SBC |
|
Vista HD27 HDHP HMO |
01/01/2024 | Summary | SBC |
|
Vista HD28 HDHP HMO |
01/01/2024 | Summary | SBC |
|
Vista HD30 HDHP HMO |
01/01/2024 | Summary | SBC |
|
Vista HD31 HDHP HMO |
01/01/2024 | Summary | SBC |
|
Vista HD32 HDHP HMO |
01/01/2024 | Summary | SBC |
|
Vista HD33 HDHP HMO |
01/01/2024 | Summary | SBC |
|
2023 Small Group Standard Medical HMO |
|||
|
Platinum MS68 HMO |
01/01/2023 | Summary | SBC |
|
Platinum MS80 HMO |
01/01/2023 | Summary | SBC |
|
Gold MS62 HMO |
01/01/2023 | Summary | SBC |
|
Gold MS77 HMO |
01/01/2023 | Summary | SBC |
|
Gold MS83 HMO |
01/01/2023 | Summary | SBC |
|
Gold SD02 HDHP HMO |
01/01/2023 | Summary | SBC |
|
Silver MS84 HMO |
01/01/2023 | Summary | SBC |
|
Silver SD01 HDHP HMO |
01/01/2023 | Summary | SBC |
|
Bronze MS86 HMO |
01/01/2023 | Summary | SBC |
|
Bronze SD48 HDHP HMO |
01/01/2023 | Summary | SBC |
|
2023 Small Group Plus Medical HMO (Contact your RBG representative for a Plus HMO plan quote) |
|||
|
Platinum MP68 Plus HMO |
01/01/2023 | Summary | SBC |
|
Platinum MP80 Plus HMO |
01/01/2023 | Summary | SBC |
|
Gold MP62 Plus HMO |
01/01/2023 | Summary | SBC |
|
Gold MP77 Plus HMO |
01/01/2023 | Summary | SBC |
|
Gold MP83 Plus HMO |
01/01/2023 | Summary | SBC |
|
Gold SP02 HDHP Plus HMO |
01/01/2023 | Summary | SBC |
|
Silver MP84 Plus HMO |
01/01/2023 | Summary | SBC |
|
Silver SP01 HDHP Plus HMO |
01/01/2023 | Summary | SBC |
|
Bronze MP86 Plus HMO |
01/01/2023 | Summary | SBC |
|
Bronze SP48 HDHP Plus HMO |
01/01/2023 | Summary | SBC |
|
2023 Large Group Medical HMO |
|||
|
Summit ML61 HMO |
01/01/2023 | Summary | SBC |
|
Summit ML62 HMO |
01/01/2023 | Summary | SBC |
|
Summit ML63 HMO |
01/01/2023 | Summary | SBC |
|
Summit ML64 HMO |
01/01/2023 | Summary | SBC |
|
Summit ML65 HMO |
01/01/2023 | Summary | SBC |
|
Summit ML66 HMO |
01/01/2023 | Summary | SBC |
|
Summit ML67 HMO |
01/01/2023 | Summary | SBC |
|
Peak ML68 HMO |
01/01/2023 | Summary | SBC |
|
Peak ML69 HMO |
01/01/2023 | Summary | SBC |
|
Peak ML70 HMO |
01/01/2023 | Summary | SBC |
|
Peak ML71 HMO |
01/01/2023 | Summary | SBC |
|
Peak ML72 HMO |
01/01/2023 | Summary | SBC |
|
Peak ML73 HMO |
01/01/2023 | Summary | SBC |
|
Peak ML77 HMO |
01/01/2023 | Summary | SBC |
|
Ridge ML74 HMO |
01/01/2023 | Summary | SBC |
|
Ridge ML75 HMO |
01/01/2023 | Summary | SBC |
|
Ridge ML76 HMO |
01/01/2023 | Summary | SBC |
|
Vista HD20 HDHP HMO |
01/01/2023 | Summary | SBC |
|
Vista HD21 HDHP HMO |
01/01/2023 | Summary | SBC |
|
Vista HD22 HDHP HMO |
01/01/2023 | Summary | SBC |
|
Vista HD23 HDHP HMO |
01/01/2023 | Summary | SBC |
|
Vista HD24 HDHP HMO |
01/01/2023 | Summary | SBC |
|
Vista HD25 HDHP HMO |
01/01/2023 | Summary | SBC |
|
Vista HD26 HDHP HMO |
01/01/2023 | Summary | SBC |
| Form Name | Effective Date | Download Form |
|---|---|---|
|
General Information |
||
|
Small Group Medical Plan Comparisons 1.24 |
01/01/2024 | Download |
|
Small Group Underwriting Guidelines 1.24 |
01/01/2024 | Download |
|
Large Group Medical Plan Comparisons 1.24 |
01/01/2024 | Download |
|
Optional Benefits Plan Comparisons 1.24 |
01/01/2024 | Download |
|
Employer Premium Payment Options Flyer |
01/01/2022 | Download |
|
Health Maintenance Guidelines |
04/01/2024 | Download |
|
Helpful Information & Resources Flyer |
04/01/2024 | Download |
|
In Your Community Access to Care - Bay Area |
04/01/2024 | Download |
|
Member Booklet - Great Coverage Starts Here |
04/01/2024 | Download |
|
Pharmacy Benefits - Managing Your Prescriptions |
01/01/2022 | Download |
|
Pharmacy Drug List 4.24 |
04/01/2024 | Download |
