Blue Shield of California

Form Name	Effective Date	Download Form
New Group Submission
New Group Submission Checklist	01/01/2018	Download
Express Enrollment Guidelines	01/01/2018	Download
Employer Application 7.18 to 9.18 Effective	07/01/2018	Download
Employer Application 10.18 to 12.18 Effective	10/01/2018	Download
Eligibility-Participation Attestation (for groups with 10+ enrolling employees)	01/01/2018	Download
Sole Proprietor, Partner, or Corporate Officer Statement	01/01/2018	Download
Small Group Check by Fax Form	06/01/2018	Download
In Force Group Forms
Employer Request For Contract Change Form 7.18 to 9.18 Effective	07/01/2018	Download
Employer Request For Contract Change Form 10.18 to 12.18 Effective	10/01/2018	Download
Blue Shield Multiple Subscriber Change Spreadsheet	03/01/2018	Download
Employee Cancellation Transmittal Request	01/01/2018	Download
Employer Notification of Qualifying Events under Cal-COBRA	01/01/2018	Download
CMS Reporting Form	01/01/2018	Download
Group Information Update Form	10/01/2018	Download
Administration
2018 Group Administrator's Guide	01/01/2018	Download
Employer Connection Plus QuickStart Guide	01/01/2018	Download
Employer Connection Plus FAQ	01/01/2018	Download
Employer Connection Plus Online Bill Payment FAQ	01/01/2018	Download
Employer Connection Plus Open Enrollment Guide	01/01/2018	Download

Form Name	Effective Date	Download Form
Enrollment and Change Forms
Small Group Employee Application 7.18 to 9.18 Effective	07/01/2018	Download
Small Group Employee Application 10.18 to 12.18 Effective	10/01/2018	Download
Refusal of Coverage Form	01/01/2018	Download
Continuity of Care Program Brochure	01/01/2018	Download
Continuity of Care Services Request Form	01/01/2018	Download
Declaration of Disability for Over-Age Dependent Child	01/01/2018	Download
Prior Carrier Deductible Instructions and Form	01/01/2018	Download
Subscriber Change Request Form 7.18 to 9.18 Effective	07/01/2018	Download
Subscriber Change Request Form 10.18 to 12.18 Effective	10/01/2018	Download
COBRA and Cal-COBRA Forms
COBRA Continuation of Coverage Application	01/01/2018	Download
Continuing Group Coverage After Federal COBRA Cal-COBRA Election Form	01/01/2018	Download
Cal-COBRA Take-Over Form	01/01/2018	Download
Cal-COBRA Election Form	01/01/2018	Download
Cal-COBRA Dental Election Form	01/01/2018	Download
Claim Forms
Authorization for the Use or Disclosure of Health Information	01/01/2018	Download
Medical Claim Form	01/01/2018	Download
Medical Claim Form - Blue Shield Life	01/01/2018	Download
Pharmacy Reimbursement Form	01/01/2018	Download
International Claim Form	01/01/2018	Download
Dental Claim Form	01/01/2018	Download
Vision Claim Form	01/01/2018	Download
Proof of Death Form - Group Life	01/01/2018	Download
Dismemberment Claim Form - Group Life	01/01/2018	Download
Accelerated Death Benefit Claim Form - Group Life	01/01/2018	Download
Waiver of Premium Claim Form - Group Life	01/01/2018	Download

Form Name	Effective Date	Download Form
2018 Medical HMO Off-Exchange Package
Access+ HMO Network
Platinum Access+ HMO 0/20 OffEx	01/01/2018	Summary	SBC
Platinum Access+ HMO 0/20 OffEx INF (with Infertility Rider)	01/01/2018		SBC
Platinum Access+ HMO 0/25 OffEx	01/01/2018	Summary	SBC
Platinum Access+ HMO 0/25 OffEx INF (with Infertility Rider)	01/01/2018		SBC
Platinum Access+ HMO 0/30 OffEx	01/01/2018	Summary	SBC
Platinum Access+ HMO 0/30 OffEx INF (with Infertility Rider)	01/01/2018		SBC
Gold Access+ HMO 500/35 OffEx	01/01/2018	Summary	SBC
Gold Access+ HMO 500/35 OffEx INF (with Infertility Rider)	01/01/2018		SBC
Gold Access+ HMO 1700/35 OffEx	01/01/2018	Summary	SBC
Gold Access+ HMO 1700/35 OffEx INF (with Infertility Rider)	01/01/2018		SBC
Silver Access+ HMO 1750/55 OffEx	01/01/2018	Summary	SBC
Silver Access+ HMO 1750/55 OffEx INF (with Infertility Rider)	01/01/2018		SBC
Local Access+ HMO Network
Platinum Local Access+ HMO 0/20 OffEx	01/01/2018	Summary	SBC
Platinum Local Access+ HMO 0/20 OffEx INF (with Infertility Rider)	01/01/2018		SBC
Platinum Local Access+ HMO 0/25 OffEx	01/01/2018	Summary	SBC
Platinum Local Access+ HMO 0/25 OffEx INF (with Infertility Rider)	01/01/2018		SBC
Platinum Local Access+ HMO 0/30 OffEx	01/01/2018	Summary	SBC
Platinum Local Access+ HMO 0/30 OffEx INF (with Infertility Rider)	01/01/2018		SBC
Gold Local Access+ HMO 500/35 OffEx	01/01/2018	Summary	SBC
Gold Local Access+ HMO 500/35 OffEx INF (with Infertility Rider)	01/01/2018		SBC
Gold Local Access+ HMO 1700/35 OffEx	01/01/2018	Summary	SBC
Gold Local Access+ HMO 1700/35 OffEx INF (with Infertility Rider)	01/01/2018		SBC
Silver Local Access+ HMO 1750/55 OffEx	01/01/2018	Summary	SBC
Silver Local Access+ HMO 1750/55 OffEx INF (with Infertility Rider)	01/01/2018		SBC
Trio HMO Network
Platinum Trio HMO 0/20 OffEx	01/01/2018	Summary	SBC
Platinum Trio HMO 0/20 OffEx INF (with Infertility Rider)	01/01/2018		SBC
Platinum Trio HMO 0/25 OffEx	01/01/2018	Summary	SBC
Platinum Trio HMO 0/25 OffEx INF (with Infertility Rider)	01/01/2018		SBC
Platinum Trio HMO 0/30 OffEx	01/01/2018	Summary	SBC
Platinum Trio HMO 0/30 OffEx INF (with Infertility Rider)	01/01/2018		SBC
Gold Trio HMO 500/35 OffEx	01/01/2018	Summary	SBC
Gold Trio HMO 500/35 OffEx INF (with Infertility Rider)	01/01/2018		SBC
Gold Trio HMO 1700/35 OffEx	01/01/2018	Summary	SBC
Gold Trio HMO 1700/35 OffEx INF (with Infertility Rider)	01/01/2018		SBC
Silver Trio HMO 1750/55 OffEx	01/01/2018	Summary	SBC
Silver Trio HMO 1750/55 OffEx INF (with Infertility Rider)	01/01/2018		SBC
2018 Medical PPO Off-Exchange Package
Full PPO Network
Platinum Full PPO 0/10 OffEx	01/01/2018	Summary	SBC
Platinum Full PPO 0/10 OffEx INF (with Infertility Rider)	01/01/2018		SBC
Platinum Full PPO 250/15 OffEx	01/01/2018	Summary	SBC
Platinum Full PPO 250/15 OffEx INF (with Infertility Rider)	01/01/2018		SBC
Gold Full PPO 0/20 OffEx	01/01/2018	Summary	SBC
Gold Full PPO 0/20 OffEx INF (with Infertility Rider)	01/01/2018		SBC
Gold Full PPO 450/30 OffEx	01/01/2018	Summary	SBC
Gold Full PPO 450/30 OffEx INF (with Infertility Rider)	01/01/2018		SBC
Gold Full PPO 750/30 OffEx	01/01/2018	Summary	SBC
Gold Full PPO 750/30 OffEx INF (with Infertility Rider)	01/01/2018		SBC
Gold Full PPO 1200/35 OffEx	01/01/2018	Summary	SBC
Gold Full PPO 1200/35 OffEx INF (with Infertility Rider)	01/01/2018		SBC
Silver Full PPO 1700/55 OfEx	01/01/2018	Summary	SBC
Silver Full PPO 1700/55 OfEx INF (with Infertility Rider)	01/01/2018		SBC
Silver Full PPO 2000/45 OffEx	01/01/2018	Summary	SBC
Silver Full PPO 2000/45 OffEx INF (with Infertility Rider)	01/01/2018		SBC
Silver Full PPO Savings 2000/20% OffEx	01/01/2018	Summary	SBC
Silver Full PPO Savings 2000/20% OffEx INF (with Infertility Rider)	01/01/2018		SBC
Bronze Full PPO 3750/65 OffEx	01/01/2018	Summary	SBC
Bronze Full PPO 3750/65 OffEx INF (with Infertility Rider)	01/01/2018		SBC
Bronze Full PPO 5700/60 OffEx	01/01/2018	Summary	SBC
Bronze Full PPO 5700/60 OffEx INF (with Infertility Rider)	01/01/2018		SBC
Bronze Full PPO Savings 4300/40% OffEx	01/01/2018	Summary	SBC
Bronze Full PPO Savings 4300/40% OffEx INF (with Infertility Rider)	01/01/2018		SBC
Bronze Full PPO Savings 6550 OffEx	01/01/2018	Summary	SBC
Bronze Full PPO Savings 6550 OffEx INF (with Infertility Rider)	01/01/2018		SBC
Tandem PPO Network
Platinum Tandem PPO 0/10 OffEx	01/01/2018	Summary	SBC
Platinum Tandem PPO 0/10 OffEx INF (with Infertility Rider)	01/01/2018		SBC
Platinum Tandem PPO 250/15 OffEx	01/01/2018	Summary	SBC
Platinum Tandem PPO 250/15 OffEx INF (with Infertility Rider)	01/01/2018		SBC
Gold Tandem PPO 750/30 OffEx	01/01/2018	Summary	SBC
Gold Tandem PPO 750/30 OffEx INF (with Infertility Rider)	01/01/2018		SBC
Silver Tandem PPO 1700/55 OffEx	01/01/2018	Summary	SBC
Silver Tandem PPO 1700/55 OffEx INF (with Infertility Rider)	01/01/2018		SBC
Silver Tandem PPO 2000/45 OffEx	01/01/2018	Summary	SBC
Silver Tandem PPO 2000/45 OffEx INF (with Infertility Rider)	01/01/2018		SBC
Bronze Tandem PPO 3750/65 OffEx	01/01/2018	Summary	SBC
Bronze Tandem PPO 3750/65 OffEx INF (with Infertility Rider)	01/01/2018		SBC
2018 Medical HMO Mirror Package
Platinum 90 HMO 0/15 Trio + Child Dental	01/01/2018	Summary	SBC
Platinum 90 HMO 0/15 Trio + Child Dental INF (with Infertility Rider)	01/01/2018		SBC
Gold 80 HMO 0/25 Trio + Child Dental	01/01/2018	Summary	SBC
Gold 80 HMO 0/25 Trio + Child Dental INF (with Infertility Rider)	01/01/2018		SBC
Silver 70 HMO 2000/45 Trio + Child Dental	01/01/2018	Summary	SBC
Silver 70 HMO 2000/45 Trio + Child Dental INF (with Infertility Rider)	01/01/2018		SBC
2018 Medical PPO Mirror Package
Platinum 90 PPO 0/15 + Child Dental	01/01/2018	Summary	SBC
Platinum 90 PPO 0/15 + Child Dental INF (with Infertility Rider)	01/01/2018		SBC
Gold 80 PPO 0/25 + Child Dental	01/01/2018	Summary	SBC
Gold 80 PPO 0/25 + Child Dental INF (with Infertility Rider)	01/01/2018		SBC
Silver 70 PPO 2000/45 + Child Dental	01/01/2018	Summary	SBC
Silver 70 PPO 2000/45 + Child Dental INF (with Infertility Rider)	01/01/2018		SBC
Bronze 60 PPO 6300/75 + Child Dental	01/01/2018	Summary	SBC
Bronze 60 PPO 6300/75 + Child Dental INF (with Infertility Rider)	01/01/2018		SBC
2018 Infertility Riders
Infertility Rider for HMO Plans	01/01/2018	Summary
Infertility Rider for PPO and HSA Plans	01/01/2018	Summary
2018 Disclosures
HMO Plans for Small Business Disclosure	01/01/2018	Summary
PPO Plans for Small Business Disclosure	01/01/2018	Summary
PPO Savings (HSA) Plans for Small Business Disclosure	01/01/2018	Summary
2017 Medical HMO Off-Exchange Package
Access+ HMO Network
Platinum Access+ HMO 0/20 OffEx	01/01/2017		SBC
Platinum Access+ HMO 0/25 OffEx	01/01/2017		SBC
Platinum Access+ HMO 0/30 OffEx	01/01/2017		SBC
Gold Access+ HMO 500/35 OffEx	01/01/2017		SBC
Gold Access+ HMO 1700/30 OffEx	01/01/2017		SBC
Silver Access+ HMO 1700/55 OffEx	01/01/2017		SBC
Local Access+ HMO Network
Platinum Local Access+ HMO 0/20 OffEx	01/01/2017		SBC
Platinum Local Access+ HMO 0/25 OffEx	01/01/2017		SBC
Platinum Local Access+ HMO 0/30 OffEx	01/01/2017		SBC
Gold Local Access+ HMO 500/35 OffEx	01/01/2017		SBC
Gold Local Access+ HMO 1700/30 OffEx	01/01/2017		SBC
Silver Local Access+ HMO 1700/55 OffEx	01/01/2017		SBC
Trio ACO HMO Network
Platinum Trio ACO HMO 0/20 OffEx	01/01/2017		SBC
Platinum Trio ACO HMO 0/25 OffEx	01/01/2017		SBC
Platinum Trio ACO HMO 0/30 OffEx	01/01/2017		SBC
Gold Trio ACO HMO 500/35 OffEx	01/01/2017		SBC
Gold Trio ACO HMO 1700/30 OffEx	01/01/2017		SBC
Silver Trio ACO HMO 1700/55 OffEx	01/01/2017		SBC
2017 Medical PPO Off-Exchange Package
Platinum Full PPO 0/10 OffEx	01/01/2017		SBC
Platinum Full PPO 150/15 OffEx	01/01/2017		SBC
Gold Full PPO 0/20 OffEx	01/01/2017		SBC
Gold Full PPO 250/30 OffEx	01/01/2017		SBC
Gold Full PPO 750/20 OffEx	01/01/2017		SBC
Gold Full PPO 1000/35 OffEx	01/01/2017		SBC
Silver Full PPO 1300/45 OffEx	01/01/2017		SBC
Silver Full PPO 1700/40 OffEx	01/01/2017		SBC
Silver Full PPO Savings 2000/20% OffEx	01/01/2017		SBC
Bronze Full PPO 3750/65 OffEx	01/01/2017		SBC
Bronze Full PPO 5100/60 OffEx	01/01/2017		SBC
Bronze Full PPO Savings 4700/40% OffEx	01/01/2017		SBC
Bronze Full PPO Savings 5500/40% OffEx	01/01/2017		SBC
2017 Medical HMO Mirror Package
Platinum 90 HMO 0/15 + Child Dental INF	01/01/2017		SBC
Gold 80 HMO 0/30 + Child Dental INF	01/01/2017		SBC
Silver 70 HMO 2000/45 + Child Dental INF	01/01/2017		SBC
2017 Medical PPO Mirror Package
Platinum 90 PPO 0/15 + Child Dental	01/01/2017		SBC
Platinum 90 PPO 0/15 + Child Dental INF	01/01/2017		SBC
Gold 80 PPO 0/30 + Child Dental	01/01/2017		SBC
Gold 80 PPO 0/30 + Child Dental INF	01/01/2017		SBC
Silver 70 PPO 2000/45 + Child Dental	01/01/2017		SBC
Silver 70 PPO 2000/45 + Child Dental INF	01/01/2017		SBC
Bronze 60 PPO 6300/75 + Child Dental	01/01/2017		SBC
Bronze 60 PPO 6300/75 + Child Dental INF	01/01/2017		SBC
2018 Dental Plans
DHMO Plans
Dental HMO Basic	01/01/2018	Summary
Dental HMO Plus	01/01/2018	Summary
Dental HMO Deluxe	01/01/2018	Summary
Dental HMO Voluntary	01/01/2018	Summary
Dental PPO Plans
Ultimate Dental PPO for Small Business 50/2000 MAC	01/01/2018	Summary
Ultimate Dental Plus PPO for Small Business 50/2000 MAC	01/01/2018	Summary
Smile Deluxe 2000 50/2000/No Ortho/MAC	01/01/2018	Summary
Smile Deluxe Plus 2000 50/2000 Ortho/MAC	01/01/2018	Summary
Smile Deluxe 50/1500 Ortho/MAC	01/01/2018	Summary
Smile Deluxe Gold 50/1500 Ortho/U85	01/01/2018	Summary
Smile 50/1500/No Ortho/MAC	01/01/2018	Summary
Smile Plus 50/1500 Ortho/MAC	01/01/2018	Summary
Smile Value 50/1500/No Ortho/MAC	01/01/2018	Summary
Smile Plus Gold 50/1500 Ortho/U85	01/01/2018	Summary
Smile Basic 75/1000/No Ortho/MAC	01/01/2018	Summary
Smile Basic Voluntary 75/1000/No Ortho/MAC	01/01/2018	Summary
Dental INO Plans
Smile INO Dental Plan 50/1500/Endo-Perio 80%/No Ortho	01/01/2018	Summary
Smile INO Dental Plan 50/1500/Endo-Perio 80%/Ortho	01/01/2018	Summary
Smile INO Dental Plan 50/2500 Endo-Perio 80%/No Ortho	01/01/2018	Summary
Smile INO Dental Plan 50/2500 Endo-Perio 80%/Ortho	01/01/2018	Summary
Smile INO Dental Voluntary Plan 50/1500 Endo-Perio 50%/No Ortho	01/01/2018	Summary
Smile INO Dental Voluntary Plan 50/1500 Endo-Perio 50%/Ortho	01/01/2018	Summary
Smile INO Dental Voluntary Plan 50/2500 Endo-Perio 50%/No Ortho	01/01/2018	Summary
Smile INO Dental Voluntary Plan 50/2500 Endo-Perio 50%/Ortho	01/01/2018	Summary
2018 Vision Plans
Enhanced Vision Plans (12/24/24)
Enhanced Vision 0/0/120	01/01/2018	Summary
Enhanced Vision 0/0/150	01/01/2018	Summary
Enhanced Vision 15/25/120	01/01/2018	Summary
Enhanced Vision 15/25/150	01/01/2018	Summary
Enhanced Vision Plus 0/0/150/120	01/01/2018	Summary
Enhanced Vision Plus 15/25/150/120	01/01/2018	Summary
Enhanced Vision Voluntary 15/25/120	01/01/2018	Summary
Preferred Vision Plans (12/12/24)
Preferred Vision 0/0/120	01/01/2018	Summary
Preferred Vision 0/0/150	01/01/2018	Summary
Preferred Vision 15/25/120	01/01/2018	Summary
Preferred Vision 15/25/150	01/01/2018	Summary
Preferred Vision Plus 0/0/150/120	01/01/2018	Summary
Preferred Vision Plus 15/25/150/120	01/01/2018	Summary
Preferred Vision Voluntary 15/25/120	01/01/2018	Summary
Ultimate Vision Plans (12/12/12)
Ultimate Vision 0/0/120	01/01/2018	Summary
Ultimate Vision 0/0/150	01/01/2018	Summary
Ultimate Vision 15/25/120	01/01/2018	Summary
Ultimate Vision 15/25/150	01/01/2018	Summary
Ultimate Vision Plus 0/0/150/120	01/01/2018	Summary
Ultimate Vision Plus 15/25/150/120	01/01/2018	Summary
Ultimate Vision Voluntary 15/25/150	01/01/2018	Summary
2018 Basic Group Term Life and AD&D Flat Benefit Plans
Basic Group Term Life and AD&D - $15,000	01/01/2018	Summary
Basic Group Term Life and AD&D - $20,000	01/01/2018	Summary
Basic Group Term Life and AD&D - $25,000	01/01/2018	Summary
Basic Group Term Life and AD&D - $30,000	01/01/2018	Summary
Basic Group Term Life and AD&D - $50,000	01/01/2018	Summary
Basic Group Term Life and AD&D - $75,000	01/01/2018	Summary
Basic Group Term Life and AD&D - $100,000	01/01/2018	Summary
Basic Group Term Life and AD&D - $150,000	01/01/2018	Summary

Form Name	Effective Date	Download Form
General Information
Blue Shield Employer Connection Plus 2018 Tool Enhancements FAQ	07/01/2018	Download
Blue Shield Sales Guide 4.18 and Later Effective	04/01/2018	Download
Blue Shield - Insurance Industry Glossary	01/01/2018	Download
How to Access Your Benefits Online	01/01/2018	Download
Online and Mobile Tools	01/01/2018	Download
Relaxed Participation Guidelines through 9.18 Effective	01/01/2018	Download
Small Group Underwriting Guidelines 4.18 and Later Effective	04/01/2018	Download
What's New for Small Group Q1 2018	01/01/2018	Download
What's New for Small Group Q2 2018	04/01/2018	Download
What's New for Small Group Q3 2018	07/01/2018	Download
Why Blue Shield of California	01/01/2018	Download
Medical
Access to Care Flyer	01/01/2018	Download
Away from Home Care for HMO Members	01/01/2018	Download
Blue Card Program for Care Outside California for PPO Members	01/01/2018	Download
Blue Shield Network Guide	01/01/2018	Download
Easy Steps to Print or Order your ID Card	01/01/2018	Download
Epic Hearing Discounts	01/01/2018	Download
Heal Physician Flyer for PPO Members	01/01/2018	Download
MailOrder Rx Flyer	01/01/2018	Download
Member Discount Programs	01/01/2018	Download
NurseHelp Employee Flyer	01/01/2018	Download
NurseHelp Employer Brochure	01/01/2018	Download
Pediatric Dental & Vision FAQ	01/01/2018	Download
Pediatric Dental & Vision Infographic	01/01/2018	Download
Preventive Health Guidelines	01/01/2018	Download
Provider Search Instructions	01/01/2018	Download
Shield Concierge for Trio Members	01/01/2018	Download
Tandem PPO Broker/Employer Flyer	01/01/2018	Download
Tandem PPO Member Flyer	01/01/2018	Download
Teladoc Flyer	01/01/2018	Download
Treatment Cost Estimator PPO Member Flyer	01/01/2018	Download
Treatment Cost Estimator Step by Step for PPO Members	01/01/2018	Download
Trio HMO Brochure	01/01/2018	Download
Trio HMO Conversion Brochure	01/01/2018	Download
Trio HMO Walkadoo Flyer	01/01/2018	Download
Trio Network Guide	01/01/2018	Download
Trio Prenatal Care Flyer	01/01/2018	Download
Trio Qualification Tool	01/01/2018	Download
Urgent Care Flyer	01/01/2018	Download
Vaccines at Retail Pharmacies	01/01/2018	Download
Wellvolution flyer	01/01/2018	Download
Dental
Broker Dental Brochure	01/01/2018	Download
Broker Specialty Bundling Flyer	01/01/2018	Download
Caries Risk Management & Assessment	01/01/2018	Download
Dental Competitive Highlight Sheet	01/01/2018	Download
Dental Implant FAQ	01/01/2018	Download
Dental Network Map	01/01/2018	Download
Dental Smile Rollover Rewards Program	01/01/2018	Download
Dentist Nomination Form	01/01/2018	Download
Guide to Managing your Dental Plan Online	01/01/2018	Download
Member Guide to Orthodontic Coverage	01/01/2018	Download
Vision
Broker Vision Brochure	01/01/2018	Download
Managing Your Vision Plan Online	01/01/2018	Download
Vision Network at a Glance	01/01/2018	Download
Vision Plan Information Card for CA Members	01/01/2018	Download
Life
Broker Life Brochure	01/01/2018	Download
Basic Life/AD&D Quick Match Program Guidelines	03/01/2018	Download

Form Name	Effective Date	Download Form
Contact Sheet and Processing Times		Download
Blue Shield Contact Information for Employees	01/01/2018	Download

Blue Shield of California

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