| Form Name | Effective Date | Download Form |
|---|---|---|
|
New Group Submission |
||
|
New Business Submission Checklist 1.24 |
01/01/2024 | Download |
|
Employer Application 1.24 |
01/01/2024 | Download |
|
Small Group ACA Banking Consent Form |
01/01/2022 | Download |
|
In Force Group Forms |
||
|
Cal-COBRA Employer Notice of Qualifying Event Form |
03/01/2022 | Download |
|
Employer Verification Form |
01/01/2022 | Download |
|
Small Employer Certification Form (FTE Certification) |
01/01/2022 | Download |
|
Administration |
||
|
Employer Administrative Handbook |
02/01/2023 | Download |
|
New Customer Quick Start Guide |
01/01/2022 | Download |
| Form Name | Effective Date | Download Form |
|---|---|---|
|
Enrollment and Change Forms |
||
|
Employee Enrollment Change Form 1.24 |
01/01/2024 | Download |
|
Employee Enrollment Change Form 1.23 |
01/01/2023 | Download |
|
Request for Continuation of Coverage for Disabled Child |
01/01/2022 | Download |
|
Disabled Child Attending Physician Statement |
01/01/2022 | Download |
|
Transition of Care Form (HMO) |
01/01/2022 | Download |
|
Transition of Care Form (PPO) |
01/01/2022 | Download |
|
Claim Forms |
||
|
Authorization to Release Protected Health Information Form |
01/01/2022 | Download |
|
Medical Claim Form |
01/01/2022 | Download |
|
Pharmacy Claim Form |
01/01/2022 | Download |
|
Mail Order Rx Delivery-Registration Form |
01/01/2022 | Download |
|
Dental Claim Form |
01/01/2022 | Download |
|
Vision Claim Form (Benefits within a Medical Plan) |
01/01/2022 | Download |
|
Vision Claim Form (Benefits through Aetna Vision Preferred Plan) |
01/01/2022 | Download |
| Form Name | Effective Date | Download Form | |
|---|---|---|---|
|
2024 Medical HMO |
|||
|
Full HMO Network |
|||
|
HMO Platinum CA $20/40 0 Ded |
01/01/2024 | Summary | SBC |
|
HMO Platinum CA $20/40 0 Ded INF |
01/01/2024 | Summary | SBC |
|
HMO Gold CA $30/60 0 Ded |
01/01/2024 | Summary | SBC |
|
HMO Gold CA $30/60 0 Ded INF |
01/01/2024 | Summary | SBC |
|
HMO Gold CA $35/65 0 Ded |
01/01/2024 | Summary | SBC |
|
HMO Gold CA $35/65 0 Ded INF |
01/01/2024 | Summary | SBC |
|
HMO Gold CA $25/50 500 Ded |
01/01/2024 | Summary | SBC |
|
HMO Gold CA $25/50 500 Ded INF |
01/01/2024 | Summary | SBC |
|
HMO Gold CA $25/65 1250 Ded |
01/01/2024 | Summary | SBC |
|
HMO Gold CA $25/65 1250 Ded INF |
01/01/2024 | Summary | SBC |
|
HMO Silver CA $50/70 0 Ded |
01/01/2024 | Summary | SBC |
|
HMO Silver CA $50/70 0 Ded INF |
01/01/2024 | Summary | SBC |
|
HMO Silver CA $60/100 2500 Ded |
01/01/2024 | Summary | SBC |
|
HMO Silver CA $60/100 2500 Ded INF |
01/01/2024 | Summary | SBC |
|
HMO Bronze CA $60/95 6300 Ded M |
01/01/2024 | Summary | SBC |
|
HMO Bronze CA $60/95 6300 Ded M INF |
01/01/2024 | Summary | SBC |
|
HMO Bronze CA $75/125 8550 Ded |
01/01/2024 | Summary | SBC |
|
HMO Bronze CA $75/125 8550 Ded INF |
01/01/2024 | Summary | SBC |
|
Aetna Value Network |
|||
|
Aetna Value Network HMO Platinum CA $20/30 0 Ded M |
01/01/2024 | Summary | SBC |
|
Aetna Value Network HMO Platinum CA $20/30 0 Ded INF |
01/01/2024 | Summary | SBC |
|
Aetna Value Network HMO Platinum CA $20/40 0 Ded |
01/01/2024 | Summary | SBC |
|
Aetna Value Network HMO Platinum CA $20/40 0 Ded INF |
01/01/2024 | Summary | SBC |
|
Aetna Value Network HMO Gold CA $30/60 0 Ded |
01/01/2024 | Summary | SBC |
|
Aetna Value Network HMO Gold CA $30/60 0 Ded INF |
01/01/2024 | Summary | SBC |
|
Aetna Value Network HMO Gold CA $35/65 0 Ded |
01/01/2024 | Summary | SBC |
|
Aetna Value Network HMO Gold CA $35/65 0 Ded INF |
01/01/2024 | Summary | SBC |
|
Aetna Value Network HMO Gold CA $35/55 250 Ded M |
01/01/2024 | Summary | SBC |
|
Aetna Value Network HMO Gold CA $35/55 250 Ded INF |
01/01/2024 | Summary | SBC |
|
Aetna Value Network HMO Gold CA $25/50 500 Ded |
01/01/2024 | Summary | SBC |
|
Aetna Value Network HMO Gold CA $25/50 500 Ded INF |
01/01/2024 | Summary | SBC |
|
Aetna Value Network HMO Gold CA $25/65 1250 Ded |
01/01/2024 | Summary | SBC |
|
Aetna Value Network HMO Gold CA $25/65 1250 Ded INF |
01/01/2024 | Summary | SBC |
|
Aetna Value Network HMO Silver CA $50/70 0 Ded |
01/01/2024 | Summary | SBC |
|
Aetna Value Network HMO Silver CA $50/70 0 Ded INF |
01/01/2024 | Summary | SBC |
|
Aetna Value Network HMO Silver CA $55/90 2500 Ded M |
01/01/2024 | Summary | SBC |
|
Aetna Value Network HMO Silver CA $55/90 2500 Ded INF |
01/01/2024 | Summary | SBC |
|
Aetna Value Network HMO Silver CA $60/100 2500 Ded |
01/01/2024 | Summary | SBC |
|
Aetna Value Network HMO Silver CA $60/100 2500 Ded INF |
01/01/2024 | Summary | SBC |
|
Aetna Value Network HMO Bronze CA $75/125 8550 Ded |
01/01/2024 | Summary | SBC |
|
Aetna Value Network HMO Bronze CA $75/125 8550 Ded INF |
01/01/2024 | Summary | SBC |
|
Aetna Whole Health Network Southern CA |
|||
|
AWH Southern CA HMO Platinum CA $20/30 0 Ded M |
01/01/2024 | Summary | SBC |
|
AWH Southern CA HMO Platinum CA $20/30 0 Ded INF |
01/01/2024 | Summary | SBC |
|
AWH Southern CA HMO Platinum CA $20/40 0 Ded |
01/01/2024 | Summary | SBC |
|
AWH Southern CA HMO Platinum CA $20/40 0 Ded INF |
01/01/2024 | Summary | SBC |
|
AWH Southern CA HMO Gold CA $30/60 0 Ded |
01/01/2024 | Summary | SBC |
|
AWH Southern CA HMO Gold CA $30/60 0 Ded INF |
01/01/2024 | Summary | SBC |
|
AWH Southern CA HMO Gold CA $35/65 0 Ded |
01/01/2024 | Summary | SBC |
|
AWH Southern CA HMO Gold CA $35/65 0 Ded INF |
01/01/2024 | Summary | SBC |
|
AWH Southern CA HMO Gold CA $35/55 250 Ded M |
01/01/2024 | Summary | SBC |
|
AWH Southern CA HMO Gold CA $35/55 250 Ded INF |
01/01/2024 | Summary | SBC |
|
AWH Southern CA HMO Gold CA $25/50 500 Ded |
01/01/2024 | Summary | SBC |
|
AWH Southern CA HMO Gold CA $25/50 500 Ded INF |
01/01/2024 | Summary | SBC |
|
AWH Southern CA HMO Gold CA $25/65 1250 Ded |
01/01/2024 | Summary | SBC |
|
AWH Southern CA HMO Gold CA $25/65 1250 Ded INF |
01/01/2024 | Summary | SBC |
|
AWH Southern CA HMO Silver CA $50/70 0 Ded |
01/01/2024 | Summary | SBC |
|
AWH Southern CA HMO Silver CA $50/70 0 Ded INF |
01/01/2024 | Summary | SBC |
|
AWH Southern CA HMO Silver CA $55/90 2500 Ded M |
01/01/2024 | Summary | SBC |
|
AWH Southern CA HMO Silver CA $55/90 2500 Ded INF |
01/01/2024 | Summary | SBC |
|
AWH Southern CA HMO Silver CA $60/100 2500 Ded |
01/01/2024 | Summary | SBC |
|
AWH Southern CA HMO Silver CA $60/100 2500 Ded INF |
01/01/2024 | Summary | SBC |
|
AWH Southern CA HMO Bronze CA $75/125 8550 Ded |
01/01/2024 | Summary | SBC |
|
AWH Southern CA HMO Bronze CA $75/125 8550 Ded INF |
01/01/2024 | Summary | SBC |
|
Aetna Whole Health Network Northern CA |
|||
|
AWH Northern CA HMO Platinum CA $20/30 0 Ded M |
01/01/2024 | Summary | SBC |
|
AWH Northern CA HMO Platinum CA $20/30 0 Ded INF |
01/01/2024 | Summary | SBC |
|
AWH Northern CA HMO Platinum CA $20/40 0 Ded |
01/01/2024 | Summary | SBC |
|
AWH Northern CA HMO Platinum CA $20/40 0 Ded INF |
01/01/2024 | Summary | SBC |
|
AWH Northern CA HMO Gold CA $30/60 0 Ded |
01/01/2024 | Summary | SBC |
|
AWH Northern CA HMO Gold CA $30/60 0 Ded INF |
01/01/2024 | Summary | SBC |
|
AWH Northern CA HMO Gold CA $35/65 0 Ded |
01/01/2024 | Summary | SBC |
|
AWH Northern CA HMO Gold CA $35/65 0 Ded INF |
01/01/2024 | Summary | SBC |
|
AWH Northern CA HMO Gold CA $35/55 250 Ded M |
01/01/2024 | Summary | SBC |
|
AWH Northern CA HMO Gold CA $35/55 250 Ded INF |
01/01/2024 | Summary | SBC |
|
AWH Northern CA HMO Gold CA $25/50 500 Ded |
01/01/2024 | Summary | SBC |
|
AWH Northern CA HMO Gold CA $25/50 500 Ded INF |
01/01/2024 | Summary | SBC |
|
AWH Northern CA HMO Gold CA $25/65 1250 Ded |
01/01/2024 | Summary | SBC |
|
AWH Northern CA HMO Gold CA $25/65 1250 Ded INF |
01/01/2024 | Summary | SBC |
|
AWH Northern CA HMO Silver CA $50/70 0 Ded |
01/01/2024 | Summary | SBC |
|
AWH Northern CA HMO Silver CA $50/70 0 Ded INF |
01/01/2024 | Summary | SBC |
|
AWH Northern CA HMO Silver CA $55/90 2500 Ded M |
01/01/2024 | Summary | SBC |
|
AWH Northern CA HMO Silver CA $55/90 2500 Ded INF |
01/01/2024 | Summary | SBC |
|
AWH Northern CA HMO Silver CA $60/100 2500 Ded |
01/01/2024 | Summary | SBC |
|
AWH Northern CA HMO Silver CA $60/100 2500 Ded INF |
01/01/2024 | Summary | SBC |
|
AWH Northern CA HMO Bronze CA $75/125 8550 Ded |
01/01/2024 | Summary | SBC |
|
AWH Northern CA HMO Bronze CA $75/125 8550 Ded INF |
01/01/2024 | Summary | SBC |
|
2024 Medical PPO |
|||
|
Managed Choice POS Network |
|||
|
OA Managed Choice POS Platinum CA 90/50 0 Ded M |
01/01/2024 | Summary | SBC |
|
OA Managed Choice POS Platinum CA 90/50 0 Ded INF |
01/01/2024 | Summary | SBC |
|
OA Managed Choice POS Platinum CA 80/50 250 Ded |
01/01/2024 | Summary | SBC |
|
OA Managed Choice POS Platinum CA 80/50 250 Ded INF |
01/01/2024 | Summary | SBC |
|
OA Managed Choice POS Gold CA 80/50 350 Ded M |
01/01/2024 | Summary | SBC |
|
OA Managed Choice POS Gold CA 80/50 350 Ded INF |
01/01/2024 | Summary | SBC |
|
OA Managed Choice POS Gold CA 75/50 500 Ded |
01/01/2024 | Summary | SBC |
|
OA Managed Choice POS Gold CA 75/50 500 Ded INF |
01/01/2024 | Summary | SBC |
|
OA Managed Choice POS Gold CA 70/50 1250 Ded |
01/01/2024 | Summary | SBC |
|
OA Managed Choice POS Gold CA 70/50 1250 Ded INF |
01/01/2024 | Summary | SBC |
|
OA Managed Choice POS Gold CA 80/50 1500 Ded |
01/01/2024 | Summary | SBC |
|
OA Managed Choice POS Gold CA 80/50 1500 Ded INF |
01/01/2024 | Summary | SBC |
|
OA Managed Choice POS Gold HDHP CA 90/50 3200 Ded HSA |
01/01/2024 | Summary | SBC |
|
OA Managed Choice POS Gold HDHP CA 90/50 3200 Ded HSA INF |
01/01/2024 | Summary | SBC |
|
OA Managed Choice POS Silver CA 60/50 2100 Ded |
01/01/2024 | Summary | SBC |
|
OA Managed Choice POS Silver CA 60/50 2100 Ded INF |
01/01/2024 | Summary | SBC |
|
OA Managed Choice POS Silver CA Copay Plan 65/50 2500 Ded M |
01/01/2024 | Summary | SBC |
|
OA Managed Choice POS Silver CA Copay Plan 65/50 2500 Ded INF |
01/01/2024 | Summary | SBC |
|
OA Managed Choice POS Silver CA 65/50 2600 Ded |
01/01/2024 | Summary | SBC |
|
OA Managed Choice POS Silver CA 65/50 2600 Ded INF |
01/01/2024 | Summary | SBC |
|
OA Managed Choice POS Bronze CA 55/50 5500 Ded |
01/01/2024 | Summary | SBC |
|
OA Managed Choice POS Bronze CA 55/50 5500 Ded INF |
01/01/2024 | Summary | SBC |
|
OA Managed Choice POS Bronze CA 50/50 8300 Ded |
01/01/2024 | Summary | SBC |
|
OA Managed Choice POS Bronze CA 50/50 8300 Ded INF |
01/01/2024 | Summary | SBC |
|
OA Managed Choice POS Bronze HDHP CA 100 7050 Ded HSA M |
01/01/2024 | Summary | SBC |
|
OA Managed Choice POS Bronze HDHP CA 100 7050 Ded HSA INF |
01/01/2024 | Summary | SBC |
|
Savings Plus Managed Choice POS Network |
|||
|
Savings Plus OA Managed Choice POS Platinum CA 90/50 0 Ded M |
01/01/2024 | Summary | SBC |
|
Savings Plus OA Managed Choice POS Platinum CA 90/50 0 Ded INF |
01/01/2024 | Summary | SBC |
|
Savings Plus OA Managed Choice POS Platinum CA 80/50 250 Ded |
01/01/2024 | Summary | SBC |
|
Savings Plus OA Managed Choice POS Platinum CA 80/50 250 Ded INF |
01/01/2024 | Summary | SBC |
|
Savings Plus OA Managed Choice POS Gold CA 80/50 350 Ded M |
01/01/2024 | Summary | SBC |
|
Savings Plus OA Managed Choice POS Gold CA 80/50 350 Ded INF |
01/01/2024 | Summary | SBC |
|
Savings Plus OA Managed Choice POS Gold CA 75/50 500 Ded |
01/01/2024 | Summary | SBC |
|
Savings Plus OA Managed Choice POS Gold CA 75/50 500 Ded INF |
01/01/2024 | Summary | SBC |
|
Savings Plus OA Managed Choice POS Gold CA 70/50 1250 Ded |
01/01/2024 | Summary | SBC |
|
Savings Plus OA Managed Choice POS Gold CA 70/50 1250 Ded INF |
01/01/2024 | Summary | SBC |
|
Savings Plus OA Managed Choice POS Gold CA 80/50 1500 Ded |
01/01/2024 | Summary | SBC |
|
Savings Plus OA Managed Choice POS Gold CA 80/50 1500 Ded INF |
01/01/2024 | Summary | SBC |
|
Savings Plus OA Managed Choice POS Gold HDHP CA 90/50 3200 Ded HSA |
01/01/2024 | Summary | SBC |
|
Savings Plus OA Managed Choice POS Gold HDHP CA 90/50 3200 Ded HSA INF |
01/01/2024 | Summary | SBC |
|
Savings Plus OA Managed Choice POS Silver CA 60/50 2100 Ded |
01/01/2024 | Summary | SBC |
|
Savings Plus OA Managed Choice POS Silver CA 60/50 2100 Ded INF |
01/01/2024 | Summary | SBC |
|
Savings Plus OA Managed Choice POS Silver CA 65/50 2600 Ded |
01/01/2024 | Summary | SBC |
|
Savings Plus OA Managed Choice POS Silver CA 65/50 2600 Ded INF |
01/01/2024 | Summary | SBC |
|
Savings Plus OA Managed Choice POS Silver CA Copay Plan 65/50 2500 Ded M |
01/01/2024 | Summary | SBC |
|
Savings Plus OA Managed Choice POS Silver CA Copay Plan 65/50 2500 Ded INF |
01/01/2024 | Summary | SBC |
|
Savings Plus OA Managed Choice POS Bronze CA 55/50 5500 Ded |
01/01/2024 | Summary | SBC |
|
Savings Plus OA Managed Choice POS Bronze CA 55/50 5500 Ded INF |
01/01/2024 | Summary | SBC |
|
Savings Plus OA Managed Choice POS Bronze CA 50/50 8300 Ded |
01/01/2024 | Summary | SBC |
|
Savings Plus OA Managed Choice POS Bronze CA 50/50 8300 Ded INF |
01/01/2024 | Summary | SBC |
|
Savings Plus OA Managed Choice POS Bronze HDHP CA 100 7050 Ded HSA M |
01/01/2024 | Summary | SBC |
|
Savings Plus OA Managed Choice POS Bronze HDHP CA 100 7050 Ded HSA INF |
01/01/2024 | Summary | SBC |
|
PPO Network (available to out-of-state employees only not in a Managed Choice area) |
|||
|
Open Choice PPO Gold CA 80/50 1000 Ded |
01/01/2024 | Summary | SBC |
|
Open Choice PPO Gold CA 80/50 1000 Ded INF |
01/01/2024 | Summary | SBC |
|
Open Choice PPO Silver CA 60/50 2100 Ded |
01/01/2024 | Summary | SBC |
|
Open Choice PPO Silver CA 60/50 2100 Ded INF |
01/01/2024 | Summary | SBC |
|
Open Choice PPO Bronze CA 55/50 5500 Ded |
01/01/2024 | Summary | SBC |
|
Open Choice PPO Bronze CA 55/50 5500 Ded INF |
01/01/2024 | Summary | SBC |
|
Open Choice PPO Bronze CA 50/50 8300 Ded |
01/01/2024 | Summary | SBC |
|
Open Choice PPO Bronze CA 50/50 8300 Ded INF |
01/01/2024 | Summary | SBC |
|
2023 Medical HMO |
|||
|
Full HMO Network |
|||
|
HMO Platinum CA $20/40 0 Ded |
01/01/2023 | Summary | SBC |
|
HMO Platinum CA $20/40 0 Ded wINF |
01/01/2023 | Summary | SBC |
|
HMO Gold CA $30/60 0 Ded |
01/01/2023 | Summary | SBC |
|
HMO Gold CA $30/60 0 Ded wINF |
01/01/2023 | Summary | SBC |
|
HMO Gold CA $35/65 250 Ded |
01/01/2023 | Summary | SBC |
|
HMO Gold CA $35/65 250 Ded wINF |
01/01/2023 | Summary | SBC |
|
HMO Gold CA $25/50 500 Ded |
01/01/2023 | Summary | SBC |
|
HMO Gold CA $25/50 500 Ded wINF |
01/01/2023 | Summary | SBC |
|
HMO Gold CA $30/70 1250 Ded |
01/01/2023 | Summary | SBC |
|
HMO Gold CA $30/70 1250 Ded wINF |
01/01/2023 | Summary | SBC |
|
HMO Silver CA $50/70 0 Ded |
01/01/2023 | Summary | SBC |
|
HMO Silver CA $50/70 0 Ded wINF |
01/01/2023 | Summary | SBC |
|
HMO Silver CA $60/100 2500 Ded |
01/01/2023 | Summary | SBC |
|
HMO Silver CA $60/100 2500 Ded wINF |
01/01/2023 | Summary | SBC |
|
HMO Bronze CA $75/125 7900 Ded |
01/01/2023 | Summary | SBC |
|
HMO Bronze CA $75/125 7900 Ded wINF |
01/01/2023 | Summary | SBC |
|
Aetna Value Network |
|||
|
Aetna Value Network HMO Platinum CA $20/30 0 Ded M |
01/01/2023 | Summary | SBC |
|
Aetna Value Network HMO Platinum CA $20/30 0 Ded wINF |
01/01/2023 | Summary | SBC |
|
Aetna Value Network HMO Platinum CA $20/40 0 Ded |
01/01/2023 | Summary | SBC |
|
Aetna Value Network HMO Platinum CA $20/40 0 Ded wINF |
01/01/2023 | Summary | SBC |
|
Aetna Value Network HMO Gold CA $30/60 0 Ded |
01/01/2023 | Summary | SBC |
|
Aetna Value Network HMO Gold CA $30/60 0 Ded wINF |
01/01/2023 | Summary | SBC |
|
Aetna Value Network HMO Gold CA $35/55 250 Ded M |
01/01/2023 | Summary | SBC |
|
Aetna Value Network HMO Gold CA $35/55 250 Ded wINF |
01/01/2023 | Summary | SBC |
|
Aetna Value Network HMO Gold CA $35/65 250 Ded |
01/01/2023 | Summary | SBC |
|
Aetna Value Network HMO Gold CA $35/65 250 Ded wINF |
01/01/2023 | Summary | SBC |
|
Aetna Value Network HMO Gold CA $25/50 500 Ded |
01/01/2023 | Summary | SBC |
|
Aetna Value Network HMO Gold CA $25/50 500 Ded wINF |
01/01/2023 | Summary | SBC |
|
Aetna Value Network HMO Gold CA $30/70 1250 Ded |
01/01/2023 | Summary | SBC |
|
Aetna Value Network HMO Gold CA $30/70 1250 Ded wINF |
01/01/2023 | Summary | SBC |
|
Aetna Value Network HMO Silver CA $50/70 0 Ded |
01/01/2023 | Summary | SBC |
|
Aetna Value Network HMO Silver CA $50/70 0 Ded wINF |
01/01/2023 | Summary | SBC |
|
Aetna Value Network HMO Silver CA $55/90 2500 Ded M |
01/01/2023 | Summary | SBC |
|
Aetna Value Network HMO Silver CA $55/90 2500 Ded wINF |
01/01/2023 | Summary | SBC |
|
Aetna Value Network HMO Silver CA $60/100 2500 Ded |
01/01/2023 | Summary | SBC |
|
Aetna Value Network HMO Silver CA $60/100 2500 Ded wINF |
01/01/2023 | Summary | SBC |
|
Aetna Value Network HMO Bronze CA $75/125 7900 Ded |
01/01/2023 | Summary | SBC |
|
Aetna Value Network HMO Bronze CA $75/125 7900 Ded wINF |
01/01/2023 | Summary | SBC |
|
Basic Network |
|||
|
HMO Basic Platinum CA $20/40 0 Ded |
01/01/2023 | Summary | SBC |
|
HMO Basic Platinum CA $20/40 0 Ded wINF |
01/01/2023 | Summary | SBC |
|
HMO Basic Gold CA $30/60 0 Ded |
01/01/2023 | Summary | SBC |
|
HMO Basic Gold CA $30/60 0 Ded wINF |
01/01/2023 | Summary | SBC |
|
HMO Basic Gold CA $35/65 250 Ded |
01/01/2023 | Summary | SBC |
|
HMO Basic Gold CA $35/65 250 Ded wINF |
01/01/2023 | Summary | SBC |
|
HMO Basic Gold CA $25/50 500 Ded |
01/01/2023 | Summary | SBC |
|
HMO Basic Gold CA $25/50 500 Ded wINF |
01/01/2023 | Summary | SBC |
|
HMO Basic Gold CA $30/70 1250 Ded |
01/01/2023 | Summary | SBC |
|
HMO Basic Gold CA $30/70 1250 Ded wINF |
01/01/2023 | Summary | SBC |
|
HMO Basic Silver CA $50/70 0 Ded |
01/01/2023 | Summary | SBC |
|
HMO Basic Silver CA $50/70 0 Ded wINF |
01/01/2023 | Summary | SBC |
|
HMO Basic Silver CA $60/100 2500 Ded |
01/01/2023 | Summary | SBC |
|
HMO Basic Silver CA $60/100 2500 Ded wINF |
01/01/2023 | Summary | SBC |
|
HMO Basic Bronze CA $65/95 6300 Ded M |
01/01/2023 | Summary | SBC |
|
HMO Basic Bronze CA $65/95 6300 Ded wINF |
01/01/2023 | Summary | SBC |
|
HMO Basic Bronze CA $75/125 7900 Ded |
01/01/2023 | Summary | SBC |
|
HMO Basic Bronze CA $75/125 7900 Ded wINF |
01/01/2023 | Summary | SBC |
|
Aetna Whole Health Network Southern CA |
|||
|
AWH Southern CA HMO Platinum CA $20/30 0 Ded M |
01/01/2023 | Summary | SBC |
|
AWH Southern CA HMO Platinum CA $20/30 0 Ded wINF |
01/01/2023 | Summary | SBC |
|
AWH Southern CA HMO Platinum CA $20/40 0 Ded |
01/01/2023 | Summary | SBC |
|
AWH Southern CA HMO Platinum CA $20/40 0 Ded wINF |
01/01/2023 | Summary | SBC |
|
AWH Southern CA HMO Gold CA $30/60 0 Ded |
01/01/2023 | Summary | SBC |
|
AWH Southern CA HMO Gold CA $30/60 0 Ded wINF |
01/01/2023 | Summary | SBC |
|
AWH Southern CA HMO Gold CA $35/55 250 Ded M |
01/01/2023 | Summary | SBC |
|
AWH Southern CA HMO Gold CA $35/55 250 Ded wINF |
01/01/2023 | Summary | SBC |
|
AWH Southern CA HMO Gold CA $35/65 250 Ded |
01/01/2023 | Summary | SBC |
|
AWH Southern CA HMO Gold CA $35/65 250 Ded wINF |
01/01/2023 | Summary | SBC |
|
AWH Southern CA HMO Gold CA $25/50 500 Ded |
01/01/2023 | Summary | SBC |
|
AWH Southern CA HMO Gold CA $25/50 500 Ded wINF |
01/01/2023 | Summary | SBC |
|
AWH Southern CA HMO Gold CA $30/70 1250 Ded |
01/01/2023 | Summary | SBC |
|
AWH Southern CA HMO Gold CA $30/70 1250 Ded wINF |
01/01/2023 | Summary | SBC |
|
AWH Southern CA HMO Silver CA $50/70 0 Ded |
01/01/2023 | Summary | SBC |
|
AWH Southern CA HMO Silver CA $50/70 0 Ded wINF |
01/01/2023 | Summary | SBC |
|
AWH Southern CA HMO Silver CA $55/90 2500 Ded M |
01/01/2023 | Summary | SBC |
|
AWH Southern CA HMO Silver CA $55/90 2500 Ded wINF |
01/01/2023 | Summary | SBC |
|
AWH Southern CA HMO Silver CA $60/100 2500 Ded |
01/01/2023 | Summary | SBC |
|
AWH Southern CA HMO Silver CA $60/100 2500 Ded wINF |
01/01/2023 | Summary | SBC |
|
AWH Southern CA HMO Bronze CA $75/125 7900 Ded |
01/01/2023 | Summary | SBC |
|
AWH Southern CA HMO Bronze CA $75/125 7900 Ded wINF |
01/01/2023 | Summary | SBC |
|
Aetna Whole Health Network Northern CA |
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|
AWH Northern CA HMO Platinum CA $20/30 0 Ded M |
01/01/2023 | Summary | SBC |
|
AWH Northern CA HMO Platinum CA $20/30 0 Ded wINF |
01/01/2023 | Summary | SBC |
|
AWH Northern CA HMO Platinum CA $20/40 0 Ded |
01/01/2023 | Summary | SBC |
|
AWH Northern CA HMO Platinum CA $20/40 0 Ded wINF |
01/01/2023 | Summary | SBC |
|
AWH Northern CA HMO Gold CA $30/60 0 Ded |
01/01/2023 | Summary | SBC |
|
AWH Northern CA HMO Gold CA $30/60 0 Ded wINF |
01/01/2023 | Summary | SBC |
|
AWH Northern CA HMO Gold CA $35/55 250 Ded M |
01/01/2023 | Summary | SBC |
|
AWH Northern CA HMO Gold CA $35/55 250 Ded wINF |
01/01/2023 | Summary | SBC |
|
AWH Northern CA HMO Gold CA $35/65 250 Ded |
01/01/2023 | Summary | SBC |
|
AWH Northern CA HMO Gold CA $35/65 250 Ded wINF |
01/01/2023 | Summary | SBC |
|
AWH Northern CA HMO Gold CA $25/50 500 Ded |
01/01/2023 | Summary | SBC |
|
AWH Northern CA HMO Gold CA $25/50 500 Ded wINF |
01/01/2023 | Summary | SBC |
|
AWH Northern CA HMO Gold CA $30/70 1250 Ded |
01/01/2023 | Summary | SBC |
|
AWH Northern CA HMO Gold CA $30/70 1250 Ded wINF |
01/01/2023 | Summary | SBC |
|
AWH Northern CA HMO Silver CA $50/70 0 Ded |
01/01/2023 | Summary | SBC |
|
AWH Northern CA HMO Silver CA $50/70 0 Ded wINF |
01/01/2023 | Summary | SBC |
|
AWH Northern CA HMO Silver CA $55/90 2500 Ded M |
01/01/2023 | Summary | SBC |
|
AWH Northern CA HMO Silver CA $55/90 2500 Ded wINF |
01/01/2023 | Summary | SBC |
|
AWH Northern CA HMO Silver CA $60/100 2500 Ded |
01/01/2023 | Summary | SBC |
|
AWH Northern CA HMO Silver CA $60/100 2500 Ded wINF |
01/01/2023 | Summary | SBC |
|
AWH Northern CA HMO Bronze CA $75/125 7900 Ded |
01/01/2023 | Summary | SBC |
|
AWH Northern CA HMO Bronze CA $75/125 7900 Ded wINF |
01/01/2023 | Summary | SBC |
|
2023 Medical PPO |
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|
Managed Choice POS Network |
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|
OA Managed Choice POS Platinum CA 90/50 0 Ded M |
01/01/2023 | Summary | SBC |
|
OA Managed Choice POS Platinum CA 90/50 0 Ded wINF |
01/01/2023 | Summary | SBC |
|
OA Managed Choice POS Platinum CA 80/50 250 Ded |
01/01/2023 | Summary | SBC |
|
OA Managed Choice POS Platinum CA 80/50 250 Ded wINF |
01/01/2023 | Summary | SBC |
|
OA Managed Choice POS Gold CA 80/50 350 Ded M |
01/01/2023 | Summary | SBC |
|
OA Managed Choice POS Gold CA 80/50 350 Ded wINF |
01/01/2023 | Summary | SBC |
|
OA Managed Choice POS Gold CA 75/50 500 Ded |
01/01/2023 | Summary | SBC |
|
OA Managed Choice POS Gold CA 75/50 500 Ded wINF |
01/01/2023 | Summary | SBC |
|
OA Managed Choice POS Gold CA 70/50 1250 Ded |
01/01/2023 | Summary | SBC |
|
OA Managed Choice POS Gold CA 70/50 1250 Ded wINF |
01/01/2023 | Summary | SBC |
|
OA Managed Choice POS Gold CA 80/50 1500 Ded |
01/01/2023 | Summary | SBC |
|
OA Managed Choice POS Gold CA 80/50 1500 Ded wINF |
01/01/2023 | Summary | SBC |
|
OA Managed Choice POS Gold HDHP CA 90/50 3000 Ded HSA |
01/01/2023 | Summary | SBC |
|
OA Managed Choice POS Gold HDHP CA 90/50 3000 Ded HSA wINF |
01/01/2023 | Summary | SBC |
|
OA Managed Choice POS Silver CA 60/50 2100 Ded |
01/01/2023 | Summary | SBC |
|
OA Managed Choice POS Silver CA 60/50 2100 Ded wINF |
01/01/2023 | Summary | SBC |
|
OA Managed Choice POS Silver CA Copay Plan 65/50 2500 Ded M |
01/01/2023 | Summary | SBC |
|
OA Managed Choice POS Silver CA Copay Plan 65/50 2500 Ded wINF |
01/01/2023 | Summary | SBC |
|
OA Managed Choice POS Silver CA 65/50 2600 Ded |
01/01/2023 | Summary | SBC |
|
OA Managed Choice POS Silver CA 65/50 2600 Ded wINF |
01/01/2023 | Summary | SBC |
|
OA Managed Choice POS Bronze CA 55/50 4600 Ded |
01/01/2023 | Summary | SBC |
|
OA Managed Choice POS Bronze CA 55/50 4600 Ded wINF |
01/01/2023 | Summary | SBC |
|
OA Managed Choice POS Bronze CA 100/50 7350 Ded |
01/01/2023 | Summary | SBC |
|
OA Managed Choice POS Bronze CA 100/50 7350 Ded wINF |
01/01/2023 | Summary | SBC |
|
OA Managed Choice POS Bronze CA 50/50 8300 Ded |
01/01/2023 | Summary | SBC |
|
OA Managed Choice POS Bronze CA 50/50 8300 Ded wINF |
01/01/2023 | Summary | SBC |
|
OA Managed Choice POS Bronze HDHP CA 100 7000 Ded HSA M |
01/01/2023 | Summary | SBC |
|
OA Managed Choice POS Bronze HDHP CA 100 7000 Ded HSA wINF |
01/01/2023 | Summary | SBC |
|
Savings Plus Managed Choice POS Network |
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|
Savings Plus OA Managed Choice POS Platinum CA 90/50 0 Ded M |
01/01/2023 | Summary | SBC |
|
Savings Plus OA Managed Choice POS Platinum CA 90/50 0 Ded wINF |
01/01/2023 | Summary | SBC |
|
Savings Plus OA Managed Choice POS Platinum CA 80/50 250 Ded |
01/01/2023 | Summary | SBC |
|
Savings Plus OA Managed Choice POS Platinum CA 80/50 250 Ded wINF |
01/01/2023 | Summary | SBC |
|
Savings Plus OA Managed Choice POS Gold CA 80/50 350 Ded M |
01/01/2023 | Summary | SBC |
|
Savings Plus OA Managed Choice POS Gold CA 80/50 350 Ded wINF |
01/01/2023 | Summary | SBC |
|
Savings Plus OA Managed Choice POS Gold CA 75/50 500 Ded |
01/01/2023 | Summary | SBC |
|
Savings Plus OA Managed Choice POS Gold CA 75/50 500 Ded wINF |
01/01/2023 | Summary | SBC |
|
Savings Plus OA Managed Choice POS Gold CA 70/50 1250 Ded |
01/01/2023 | Summary | SBC |
|
Savings Plus OA Managed Choice POS Gold CA 70/50 1250 Ded wINF |
01/01/2023 | Summary | SBC |
|
Savings Plus OA Managed Choice POS Gold CA 80/50 1500 Ded |
01/01/2023 | Summary | SBC |
|
Savings Plus OA Managed Choice POS Gold CA 80/50 1500 Ded wINF |
01/01/2023 | Summary | SBC |
|
Savings Plus OA Managed Choice POS Gold HDHP CA 90/50 3000 Ded HSA |
01/01/2023 | Summary | SBC |
|
Savings Plus OA Managed Choice POS Gold HDHP CA 90/50 3000 Ded HSA wINF |
01/01/2023 | Summary | SBC |
|
Savings Plus OA Managed Choice POS Silver CA 60/50 2100 Ded |
01/01/2023 | Summary | SBC |
|
Savings Plus OA Managed Choice POS Silver CA 60/50 2100 Ded wINF |
01/01/2023 | Summary | SBC |
|
Savings Plus OA Managed Choice POS Silver CA 65/50 2600 Ded |
01/01/2023 | Summary | SBC |
|
Savings Plus OA Managed Choice POS Silver CA 65/50 2600 Ded wINF |
01/01/2023 | Summary | SBC |
|
Savings Plus OA Managed Choice POS Silver CA Copay Plan 65/50 2500 Ded M |
01/01/2023 | Summary | SBC |
|
Savings Plus OA Managed Choice POS Silver CA Copay Plan 65/50 2500 Ded wINF |
01/01/2023 | Summary | SBC |
|
Savings Plus OA Managed Choice POS Bronze CA 55/50 4600 Ded |
01/01/2023 | Summary | SBC |
|
Savings Plus OA Managed Choice POS Bronze CA 55/50 4600 Ded wINF |
01/01/2023 | Summary | SBC |
|
Savings Plus OA Managed Choice POS Bronze CA 100/50 7350 Ded |
01/01/2023 | Summary | SBC |
|
Savings Plus OA Managed Choice POS Bronze CA 100/50 7350 Ded wINF |
01/01/2023 | Summary | SBC |
|
Savings Plus OA Managed Choice POS Bronze CA 50/50 8300 Ded |
01/01/2023 | Summary | SBC |
|
Savings Plus OA Managed Choice POS Bronze CA 50/50 8300 Ded wINF |
01/01/2023 | Summary | SBC |
|
Savings Plus OA Managed Choice POS Bronze HDHP CA 100 7000 Ded HSA M |
01/01/2023 | Summary | SBC |
|
Savings Plus OA Managed Choice POS Bronze HDHP CA 100 7000 Ded HSA wINF |
01/01/2023 | Summary | SBC |
|
Aetna Whole Health Network Southern CA Managed Choice POS Network |
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|
AWH Southern CA OA Managed Choice POS Platinum CA 80/50 250 Ded |
01/01/2023 | Summary | SBC |
|
AWH Southern CA OA Managed Choice POS Platinum CA 80/50 250 Ded wINF |
01/01/2023 | Summary | SBC |
|
AWH Southern CA OA Managed Choice POS Gold CA 75/50 500 Ded |
01/01/2023 | Summary | SBC |
|
AWH Southern CA OA Managed Choice POS Gold CA 75/50 500 Ded wINF |
01/01/2023 | Summary | SBC |
|
AWH Southern CA OA Managed Choice POS Gold CA 70/50 1250 Ded |
01/01/2023 | Summary | SBC |
|
AWH Southern CA OA Managed Choice POS Gold CA 70/50 1250 Ded wINF |
01/01/2023 | Summary | SBC |
|
AWH Southern CA OA Managed Choice POS Gold CA 80/50 1500 Ded |
01/01/2023 | Summary | SBC |
|
AWH Southern CA OA Managed Choice POS Gold CA 80/50 1500 Ded wINF |
01/01/2023 | Summary | SBC |
|
AWH Southern CA OA Managed Choice POS Gold HDHP CA 90/50 3000 Ded HSA |
01/01/2023 | Summary | SBC |
|
AWH Southern CA OA Managed Choice POS Gold HDHP CA 90/50 3000 Ded HSA wINF |
01/01/2023 | Summary | SBC |
|
AWH Southern CA OA Managed Choice POS Silver CA 60/50 2100 Ded |
01/01/2023 | Summary | SBC |
|
AWH Southern CA OA Managed Choice POS Silver CA 60/50 2100 Ded wINF |
01/01/2023 | Summary | SBC |
|
AWH Southern CA OA Managed Choice POS Silver CA 65/50 2600 Ded |
01/01/2023 | Summary | SBC |
|
AWH Southern CA OA Managed Choice POS Silver CA 65/50 2600 Ded wINF |
01/01/2023 | Summary | SBC |
|
AWH Southern CA OA Managed Choice POS Bronze CA 55/50 4600 Ded |
01/01/2023 | Summary | SBC |
|
AWH Southern CA OA Managed Choice POS Bronze CA 55/50 4600 Ded wINF |
01/01/2023 | Summary | SBC |
|
AWH Southern CA OA Managed Choice POS Bronze CA 100/50 7350 Ded |
01/01/2023 | Summary | SBC |
|
AWH Southern CA OA Managed Choice POS Bronze CA 100/50 7350 Ded wINF |
01/01/2023 | Summary | SBC |
|
AWH Southern CA OA Managed Choice POS Bronze CA 50/50 8300 Ded |
01/01/2023 | Summary | SBC |
|
AWH Southern CA OA Managed Choice POS Bronze CA 50/50 8300 Ded wINF |
01/01/2023 | Summary | SBC |
|
PPO Network (available to out-of-state employees only) |
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|
Open Choice PPO Gold CA 80/50 1000 Ded |
01/01/2023 | Summary | SBC |
|
Open Choice PPO Gold CA 80/50 1000 Ded wINF |
01/01/2023 | Summary | SBC |
|
Open Choice PPO Silver CA 60/50 2100 Ded |
01/01/2023 | Summary | SBC |
|
Open Choice PPO Silver CA 60/50 2100 Ded wINF |
01/01/2023 | Summary | SBC |
|
Open Choice PPO Bronze CA 55/50 4600 Ded |
01/01/2023 | Summary | SBC |
|
Open Choice PPO Bronze CA 55/50 4600 Ded wINF |
01/01/2023 | Summary | SBC |
|
Open Choice PPO Bronze CA 50/50 8300 Ded |
01/01/2023 | Summary | SBC |
|
Open Choice PPO Bronze CA 50/50 8300 Ded wINF |
01/01/2023 | Summary | SBC |
| Form Name | Effective Date | Download Form |
|---|---|---|
|
General Information |
||
|
CA Small Group Plan Guide - Benefits Toolkit 1.24 |
01/01/2024 | Download |
|
Underwriting Guidelines 1.24 |
01/01/2024 | Download |
|
Bundle Up Dental & Vision Flyer |
02/01/2024 | Download |
|
California MinuteClinic Member Flyer |
11/01/2023 | Download |
|
Discount Program Flyer (Post Enrollment) |
02/01/2024 | Download |
|
Aetna Health Assessment Program |
02/01/2024 | Download |
|
Helpful Information & Resources Flyer |
04/01/2024 | Download |
|
HMO Network Guide 1.24 |
02/01/2024 | Download |
|
California Network Map |
02/01/2024 | Download |
|
Savings Plus OAMC Network Overview |
02/01/2024 | Download |
|
Maintenance Choice Prescription Program |
02/01/2024 | Download |
|
Member Mobile App & Website Flyer |
11/01/2023 | Download |
|
Online Provider Search Instructions |
02/01/2024 | Download |
|
Prescription Drug Formulary Guide (HMO Plans) |
02/01/2024 | Download |
|
Prescription Drug Formulary Guide (OA Managed Choice & PPO Plans) |
02/01/2024 | Download |
|
Prescription Drug Maintenance Medicine List |
02/01/2024 | Download |
|
Prescription Drug Specialty Pharmacy Network |
02/01/2024 | Download |
|
Preventive Care Coverage Brochure |
11/01/2023 | Download |
|
Simple Steps Program Flyer |
11/01/2023 | Download |
|
Teladoc Pricing Flyer |
02/01/2024 | Download |
|
Telehealth & Virtual Mental Health Services Flyer |
02/01/2024 | Download |
|
Vision Preferred Flyer |
01/01/2024 | Download |
| Form Name | Effective Date | Download Form |
|---|---|---|
|
Contact Information |
01/01/2022 | Download |
