Form Name | Effective Date | Download Form |
---|---|---|
New Group Submission |
||
New Group Submission Checklist 1.22 |
01/01/2022 | Download |
Employer Application 7.23 Effective Dates |
07/01/2023 | Download |
Employer Application 1.23 Effective Dates (Revised) |
01/01/2023 | Download |
Small Business Owner Eligibility Statement |
01/01/2022 | Download |
Small Group Initial Payment Form |
07/01/2023 | Download |
Start-up Spin-off Companies Small Business Eligibility Statement |
01/01/2022 | Download |
In Force Group Forms |
||
Employer Group Change Request Form 7.23 Effective Dates |
07/01/2023 | Download |
Employer Group Change Request Form 1.23 Effective Dates (Revised) |
01/01/2023 | Download |
Employer Group Change Request Form 10.22 Effective Dates |
10/01/2022 | Download |
Group Information Update Form |
08/01/2022 | Download |
Multiple Subscriber Change Spreadsheet |
01/01/2022 | Download |
Employee Cancellation Notification |
01/01/2022 | Download |
Employer Notification of Qualifying Events under Cal-COBRA |
01/01/2022 | Download |
Broker of Record Change Request Form |
04/01/2023 | Download |
CMS Reporting Form |
01/01/2022 | Download |
Renewal Guide 2023 |
01/01/2023 | Download |
Administration |
||
2023 Group Administrator's Guide |
01/01/2023 | Download |
Employer Enrollment Tool Guide |
04/01/2023 | Download |
Form Name | Effective Date | Download Form |
---|---|---|
Enrollment and Change Forms |
||
Small Group Employee Enrollment Form 7.23 Effective Dates |
07/01/2023 | Download |
Small Group Employee Enrollment Form 1.23 Effective Dates (Revised) |
01/01/2023 | Download |
Refusal of Coverage Form 1.23 |
01/01/2023 | Download |
Continuity of Care Program Brochure |
01/01/2022 | Download |
Continuity of Care Services Request Form |
01/01/2022 | Download |
Declaration of Disability for Over-Age Dependent Child |
01/01/2022 | Download |
Prior Carrier Deductible Instructions and Form |
08/01/2022 | Download |
Subscriber Change Request Form 7.23 Effective Dates |
07/01/2023 | Download |
Subscriber Change Request Form 1.23 Effective Dates (Revised) |
01/01/2023 | Download |
Subscriber Change Request Form 10.22 Effective Dates |
10/01/2022 | Download |
COBRA and Cal-COBRA Forms |
||
Continuation of Coverage Application (COBRA and Cal-COBRA) |
01/01/2022 | Download |
Cal-COBRA Take-Over Form |
01/01/2022 | Download |
Claim Forms |
||
Authorization for the Use or Disclosure of Health Information |
01/01/2022 | Download |
Medical Claim Form |
01/01/2022 | Download |
Pharmacy Reimbursement Claim Form |
01/01/2022 | Download |
Global Care International Claim Form |
01/01/2022 | Download |
Dental Claim Form |
01/01/2022 | Download |
Vision Claim Form |
01/01/2022 | Download |
Proof of Death Form - Group Life |
01/01/2022 | Download |
Accelerated Death Benefit Claim Form - Group Life |
01/01/2022 | Download |
Dismemberment Claim Form - Group Life |
01/01/2022 | Download |
Waiver of Premium Claim Form - Group Life |
01/01/2022 | Download |
Form Name | Effective Date | Download Form | |
---|---|---|---|
2023 Medical HMO Off-Exchange Package |
|||
Access+ HMO Network |
|||
Platinum Access+ HMO 0/20 OffEx |
01/01/2023 | Summary | SBC |
Platinum Access+ HMO 0/20 OffEx INF |
01/01/2023 | SBC | |
Platinum Access+ HMO 0/25 OffEx |
01/01/2023 | Summary | SBC |
Platinum Access+ HMO 0/25 OffEx INF |
01/01/2023 | SBC | |
Platinum Access+ HMO 0/30 OffEx |
01/01/2023 | Summary | SBC |
Platinum Access+ HMO 0/30 OffEx INF |
01/01/2023 | SBC | |
Gold Access+ HMO 0/30 OffEx |
01/01/2023 | Summary | SBC |
Gold Access+ HMO 0/30 OffEx INF |
01/01/2023 | SBC | |
Gold Access+ HMO 500/35 OffEx |
01/01/2023 | Summary | SBC |
Gold Access+ HMO 500/35 OffEx INF |
01/01/2023 | SBC | |
Gold Access+ HMO 1000/35 OffEx |
01/01/2023 | Summary | SBC |
Gold Access+ HMO 1000/35 OffEx INF |
01/01/2023 | SBC | |
Gold Access+ HMO 1500/35 OffEx |
01/01/2023 | Summary | SBC |
Gold Access+ HMO 1500/35 OffEx INF |
01/01/2023 | SBC | |
Silver Access+ HMO 2300/70 OffEx |
01/01/2023 | Summary | SBC |
Silver Access+ HMO 2300/70 OffEx INF |
01/01/2023 | SBC | |
Silver Access+ HMO 2750/70 OffEx |
01/01/2023 | Summary | SBC |
Silver Access+ HMO 2750/70 OffEx INF |
01/01/2023 | SBC | |
Bronze Access+ HMO 7000/70 OffEx |
01/01/2023 | Summary | SBC |
Bronze Access+ HMO 7000/70 OffEx INF |
01/01/2023 | SBC | |
Local Access+ HMO Network |
|||
Platinum Local Access+ HMO 0/20 OffEx |
01/01/2023 | Summary | SBC |
Platinum Local Access+ HMO 0/20 OffEx INF |
01/01/2023 | SBC | |
Platinum Local Access+ HMO 0/25 OffEx |
01/01/2023 | Summary | SBC |
Platinum Local Access+ HMO 0/25 OffEx INF |
01/01/2023 | SBC | |
Platinum Local Access+ HMO 0/30 OffEx |
01/01/2023 | Summary | SBC |
Platinum Local Access+ HMO 0/30 OffEx INF |
01/01/2023 | SBC | |
Gold Local Access+ HMO 0/30 OffEx |
01/01/2023 | Summary | SBC |
Gold Local Access+ HMO 0/30 OffEx INF |
01/01/2023 | SBC | |
Gold Local Access+ HMO 500/35 OffEx |
01/01/2023 | Summary | SBC |
Gold Local Access+ HMO 500/35 OffEx INF |
01/01/2023 | SBC | |
Gold Local Access+ HMO 1000/35 OffEx |
01/01/2023 | Summary | SBC |
Gold Local Access+ HMO 1000/35 OffEx INF |
01/01/2023 | SBC | |
Gold Local Access+ HMO 1500/35 OffEx |
01/01/2023 | Summary | SBC |
Gold Local Access+ HMO 1500/35 OffEx INF |
01/01/2023 | SBC | |
Silver Local Access+ HMO 2300/70 OffEx |
01/01/2023 | Summary | SBC |
Silver Local Access+ HMO 2300/70 OffEx INF |
01/01/2023 | SBC | |
Silver Local Access+ HMO 2750/70 OffEx |
01/01/2023 | Summary | SBC |
Silver Local Access+ HMO 2750/70 OffEx INF |
01/01/2023 | SBC | |
Bronze Local Access+ HMO 7000/70 OffEx |
01/01/2023 | Summary | SBC |
Bronze Local Access+ HMO 7000/70 OffEx INF |
01/01/2023 | SBC | |
Trio HMO Network |
|||
Platinum Trio HMO 0/20 OffEx |
01/01/2023 | Summary | SBC |
Platinum Trio HMO 0/20 OffEx INF |
01/01/2023 | SBC | |
Platinum Trio HMO 0/25 OffEx |
01/01/2023 | Summary | SBC |
Platinum Trio HMO 0/25 OffEx INF |
01/01/2023 | SBC | |
Platinum Trio HMO 0/30 OffEx |
01/01/2023 | Summary | SBC |
Platinum Trio HMO 0/30 OffEx INF |
01/01/2023 | SBC | |
Gold Trio HMO 0/30 OffEx |
01/01/2023 | Summary | SBC |
Gold Trio HMO 0/30 OffEx INF |
01/01/2023 | SBC | |
Gold Trio HMO 500/35 OffEx |
01/01/2023 | Summary | SBC |
Gold Trio HMO 500/35 OffEx INF |
01/01/2023 | SBC | |
Gold Trio HMO 1000/35 OffEx |
01/01/2023 | Summary | SBC |
Gold Trio HMO 1000/35 OffEx INF |
01/01/2023 | SBC | |
Gold Trio HMO 1500/35 OffEx |
01/01/2023 | Summary | SBC |
Gold Trio HMO 1500/35 OffEx INF |
01/01/2023 | SBC | |
Silver Trio HMO 2300/70 OffEx |
01/01/2023 | Summary | SBC |
Silver Trio HMO 2300/70 OffEx INF |
01/01/2023 | SBC | |
Silver Trio HMO 2750/70 OffEx |
01/01/2023 | Summary | SBC |
Silver Trio HMO 2750/70 OffEx INF |
01/01/2023 | SBC | |
Bronze Trio HMO 7000/70 OffEx |
01/01/2023 | Summary | SBC |
Bronze Trio HMO 7000/70 OffEx INF |
01/01/2023 | SBC | |
2023 Medical PPO Off-Exchange Package |
|||
Full PPO Network |
|||
Platinum Full PPO 0/0 OffEx |
01/01/2023 | Summary | SBC |
Platinum Full PPO 0/0 OffEx INF |
01/01/2023 | SBC | |
Platinum Full PPO 0/10 OffEx |
01/01/2023 | Summary | SBC |
Platinum Full PPO 0/10 OffEx INF |
01/01/2023 | SBC | |
Platinum Full PPO 250/10 OffEx |
01/01/2023 | Summary | SBC |
Platinum Full PPO 250/10 OffEx INF |
01/01/2023 | SBC | |
Platinum Full PPO 250/15 OffEx |
01/01/2023 | Summary | SBC |
Platinum Full PPO 250/15 OffEx INF |
01/01/2023 | SBC | |
Gold Full PPO 0/25 OffEx |
01/01/2023 | Summary | SBC |
Gold Full PPO 0/25 OffEx INF |
01/01/2023 | SBC | |
Gold Full PPO 500/30 OffEx |
01/01/2023 | Summary | SBC |
Gold Full PPO 500/30 OffEx INF |
01/01/2023 | SBC | |
Gold Full PPO 750/30 OffEx |
01/01/2023 | Summary | SBC |
Gold Full PPO 750/30 OffEx INF |
01/01/2023 | SBC | |
Gold Full PPO 1000/35 OffEx |
01/01/2023 | Summary | SBC |
Gold Full PPO 1000/35 OffEx INF |
01/01/2023 | SBC | |
Gold Full PPO Savings 1750/15% HDHP PrevRx OffEx |
01/01/2023 | Summary | SBC |
Gold Full PPO Savings 1750/15% HDHP PrevRx OffEx INF |
01/01/2023 | SBC | |
Silver Full PPO 2000/60 OffEx |
01/01/2023 | Summary | SBC |
Silver Full PPO 2000/60 OffEx INF |
01/01/2023 | SBC | |
Silver Full PPO 2350/65 OffEx |
01/01/2023 | Summary | SBC |
Silver Full PPO 2350/65 OffEx INF |
01/01/2023 | SBC | |
Silver Full PPO 2550/70 OffEx |
01/01/2023 | Summary | SBC |
Silver Full PPO 2550/70 OffEx INF |
01/01/2023 | SBC | |
Silver Full PPO Savings 2300/25% OffEx |
01/01/2023 | Summary | SBC |
Silver Full PPO Savings 2300/25% OffEx INF |
01/01/2023 | SBC | |
Silver Full PPO Savings 2600/35% HDHP PrevRx OffEx |
01/01/2023 | Summary | SBC |
Silver Full PPO Savings 2600/35% HDHP PrevRx OffEx INF |
01/01/2023 | SBC | |
Bronze Full PPO 5500/65 OffEx |
01/01/2023 | Summary | SBC |
Bronze Full PPO 5500/65 OffEx INF |
01/01/2023 | SBC | |
Bronze Full PPO 6250/65 OffEx |
01/01/2023 | Summary | SBC |
Bronze Full PPO 6250/65 OffEx INF |
01/01/2023 | SBC | |
Bronze Full PPO 6500/70 OffEx |
01/01/2023 | Summary | SBC |
Bronze Full PPO 6500/70 OffEx INF |
01/01/2023 | SBC | |
Bronze Full PPO 6850/55 OffEx |
01/01/2023 | Summary | SBC |
Bronze Full PPO 6850/55 OffEx INF |
01/01/2023 | SBC | |
Bronze Full PPO 7500/65 OffEx |
01/01/2023 | Summary | SBC |
Bronze Full PPO 7500/65 OffEx INF |
01/01/2023 | SBC | |
Bronze Full PPO Savings 5700/40% OffEx |
01/01/2023 | Summary | SBC |
Bronze Full PPO Savings 5700/40% OffEx INF |
01/01/2023 | SBC | |
Bronze Full PPO Savings 7000 OffEx |
01/01/2023 | Summary | SBC |
Bronze Full PPO Savings 7000 OffEx INF |
01/01/2023 | SBC | |
Tandem PPO Network |
|||
Platinum Tandem PPO 0/0 OffEx |
01/01/2023 | Summary | SBC |
Platinum Tandem PPO 0/0 OffEx INF |
01/01/2023 | SBC | |
Platinum Tandem PPO 0/10 OffEx |
01/01/2023 | Summary | SBC |
Platinum Tandem PPO 0/10 OffEx INF |
01/01/2023 | SBC | |
Platinum Tandem PPO 250/10 OffEx |
01/01/2023 | Summary | SBC |
Platinum Tandem PPO 250/10 OffEx INF |
01/01/2023 | SBC | |
Platinum Tandem PPO 250/15 OffEx |
01/01/2023 | Summary | SBC |
Platinum Tandem PPO 250/15 OffEx INF |
01/01/2023 | SBC | |
Gold Tandem PPO 0/25 OffEx |
01/01/2023 | Summary | SBC |
Gold Tandem PPO 0/25 OffEx IN |
01/01/2023 | SBC | |
Gold Tandem PPO 500/30 OffEx |
01/01/2023 | Summary | SBC |
Gold Tandem PPO 500/30 OffEx INF |
01/01/2023 | SBC | |
Gold Tandem PPO 750/30 OffEx |
01/01/2023 | Summary | SBC |
Gold Tandem PPO 750/30 OffEx INF |
01/01/2023 | SBC | |
Gold Tandem PPO 1000/35 OffEx |
01/01/2023 | Summary | SBC |
Gold Tandem PPO 1000/35 OffEx INF |
01/01/2023 | SBC | |
Gold Tandem PPO Savings 1750/15% HDHP PrevRx OffEx |
01/01/2023 | Summary | SBC |
Gold Tandem PPO Savings 1750/15% HDHP PrevRx OffEx INF |
01/01/2023 | SBC | |
Silver Tandem PPO 2000/60 OffEx |
01/01/2023 | Summary | SBC |
Silver Tandem PPO 2000/60 OffEx INF |
01/01/2023 | SBC | |
Silver Tandem PPO 2350/65 OffEx |
01/01/2023 | Summary | SBC |
Silver Tandem PPO 2350/65 OffEx INF |
01/01/2023 | SBC | |
Silver Tandem PPO 2550/70 OffEx |
01/01/2023 | Summary | SBC |
Silver Tandem PPO 2550/70 OffEx INF |
01/01/2023 | SBC | |
Silver Tandem PPO Savings 2300/25% OffEx |
01/01/2023 | Summary | SBC |
Silver Tandem PPO Savings 2300/25% OffEx INF |
01/01/2023 | SBC | |
Silver Tandem PPO Savings 2600/35% HDHP PrevRx OffEx |
01/01/2023 | Summary | SBC |
Silver Tandem PPO Savings 2600/35% HDHP PrevRx OffEx INF |
01/01/2023 | SBC | |
Bronze Tandem PPO 5500/65 OffEx |
01/01/2023 | Summary | SBC |
Bronze Tandem PPO 5500/65 OffEx INF |
01/01/2023 | SBC | |
Bronze Tandem PPO 6250/65 OffEx |
01/01/2023 | Summary | SBC |
Bronze Tandem PPO 6250/65 OffEx INF |
01/01/2023 | SBC | |
Bronze Tandem PPO 6500/70 OffEx |
01/01/2023 | Summary | SBC |
Bronze Tandem PPO 6500/70 OffEx INF |
01/01/2023 | SBC | |
Bronze Tandem PPO 6850/55 OffEx |
01/01/2023 | Summary | SBC |
Bronze Tandem PPO 6850/55 OffEx INF |
01/01/2023 | SBC | |
Bronze Tandem PPO 7500/65 OffEx |
01/01/2023 | Summary | SBC |
Bronze Tandem PPO 7500/65 OffEx INF |
01/01/2023 | SBC | |
Bronze Tandem PPO Savings 5700/40% OffEx |
01/01/2023 | Summary | SBC |
Bronze Tandem PPO Savings 5700/40% OffEx INF |
01/01/2023 | SBC | |
Bronze Tandem PPO Savings 7000 OffEx |
01/01/2023 | Summary | SBC |
Bronze Tandem PPO Savings 7000 OffEx INF |
01/01/2023 | SBC | |
Virtual Blue Tandem PPO Network |
|||
Virtual Blue Gold Tandem PPO 1500/45 OffEx |
01/01/2023 | Summary | SBC |
Virtual Blue Gold Tandem PPO 1500/45 OffEx INF |
01/01/2023 | SBC | |
Virtual Blue Bronze Tandem PPO 7500/75 OffEx |
01/01/2023 | Summary | SBC |
Virtual Blue Bronze Tandem PPO 7500/75 OffEx INF |
01/01/2023 | SBC | |
2023 Medical HMO Mirror Package |
|||
Access+ HMO Network |
|||
Blue Shield Access+ Platinum 90 HMO 0/20 + Child Dental [New 7/1/2023] |
07/01/2023 | Summary | SBC |
Blue Shield Access+ Platinum 90 HMO 0/20 + Child Dental INF [New 7/1/2023] |
07/01/2023 | SBC | |
Blue Shield Access+ Gold 80 HMO 250/35 + Child Dental [New 7/1/2023] |
07/01/2023 | Summary | SBC |
Blue Shield Access+ Gold 80 HMO 250/35 + Child Dental INF [New 7/1/2023] |
07/01/2023 | SBC | |
Blue Shield Access+ Silver 70 HMO 2500/55 + Child Dental [New 7/1/2023] |
07/01/2023 | Summary | SBC |
Blue Shield Access+ Silver 70 HMO 2500/55 + Child Dental INF [New 7/1/2023] |
07/01/2023 | SBC | |
Trio HMO Network |
|||
Blue Shield Trio Platinum 90 HMO 0/20 + Child Dental |
01/01/2023 | Summary | SBC |
Blue Shield Trio Platinum 90 HMO 0/20 + Child Dental INF |
01/01/2023 | SBC | |
Blue Shield Trio Gold 80 HMO 250/35 + Child Dental |
01/01/2023 | Summary | SBC |
Blue Shield Trio Gold 80 HMO 250/35 + Child Dental INF |
01/01/2023 | SBC | |
Blue Shield Trio Silver 70 HMO 2500/55 + Child Dental |
01/01/2023 | Summary | SBC |
Blue Shield Trio Silver 70 HMO 2500/55 + Child Dental INF |
01/01/2023 | SBC | |
Blue Shield Bronze Trio HMO 7000/70 + Child Dental [New 7/1/2023] |
07/01/2023 | Summary | SBC |
Blue Shield Bronze Trio HMO 7000/70 + Child Dental INF [New 7/1/2023] |
07/01/2023 | SBC | |
2023 Medical PPO Mirror Package |
|||
Blue Shield Platinum 90 PPO 0/15 + Child Dental |
01/01/2023 | Summary | SBC |
Blue Shield Platinum 90 PPO 0/15 + Child Dental INF |
01/01/2023 | SBC | |
Blue Shield Gold 80 PPO 350/25 + Child Dental |
01/01/2023 | Summary | SBC |
Blue Shield Gold 80 PPO 350/25 + Child Dental INF |
01/01/2023 | SBC | |
Blue Shield Silver 70 PPO 2500/55 + Child Dental |
01/01/2023 | Summary | SBC |
Blue Shield Silver 70 PPO 2500/55 + Child Dental INF |
01/01/2023 | SBC | |
Blue Shield Silver Full PPO Savings 2300/25% + Child Dental [New 7/1/2023] |
07/01/2023 | Summary | SBC |
Blue Shield Silver Full PPO Savings 2300/25% + Child Dental INF [New 7/1/2023] |
07/01/2023 | SBC | |
Blue Shield Bronze 60 PPO 6300/65 + Child Dental |
01/01/2023 | Summary | SBC |
Blue Shield Bronze 60 PPO 6300/65 + Child Dental INF |
01/01/2023 | SBC | |
Blue Shield Bronze Full PPO Savings 7000 + Child Dental [New 7/1/2023] |
07/01/2023 | Summary | SBC |
Blue Shield Bronze Full PPO Savings 7000 + Child Dental INF [New 7/1/2023] |
07/01/2023 | SBC | |
2023 Infertility Riders |
|||
Infertility Rider for HMO Plans |
01/01/2023 | Summary | |
Infertility Rider for PPO Plans |
01/01/2023 | Summary | |
Infertility Rider for HDHP Plans |
01/01/2023 | Summary | |
2022 Medical HMO Off-Exchange Package |
|||
Access+ HMO Network |
|||
Platinum Access+ HMO 0/20 OffEx |
01/01/2022 | Summary | SBC |
Platinum Access+ HMO 0/20 OffEx INF |
01/01/2022 | SBC | |
Platinum Access+ HMO 0/25 OffEx |
01/01/2022 | Summary | SBC |
Platinum Access+ HMO 0/25 OffEx INF |
01/01/2022 | SBC | |
Platinum Access+ HMO 0/30 OffEx |
01/01/2022 | Summary | SBC |
Platinum Access+ HMO 0/30 OffEx INF |
01/01/2022 | SBC | |
Gold Access+ HMO 0/30 OffEx |
01/01/2022 | Summary | SBC |
Gold Access+ HMO 0/30 OffEx INF |
01/01/2022 | SBC | |
Gold Access+ HMO 500/35 OffEx |
01/01/2022 | Summary | SBC |
Gold Access+ HMO 500/35 OffEx INF |
01/01/2022 | SBC | |
Gold Access+ HMO 1000/35 OffEx |
01/01/2022 | Summary | SBC |
Gold Access+ HMO 1000/35 OffEx INF |
01/01/2022 | SBC | |
Gold Access+ HMO 1500/35 OffEx |
01/01/2022 | Summary | SBC |
Gold Access+ HMO 1500/35 OffEx INF |
01/01/2022 | SBC | |
Silver Access+ HMO 2000/60 OffEx |
01/01/2022 | Summary | SBC |
Silver Access+ HMO 2000/60 OffEx INF |
01/01/2022 | SBC | |
Silver Access+ HMO 2750/65 OffEx |
01/01/2022 | Summary | SBC |
Silver Access+ HMO 2750/65 OffEx INF |
01/01/2022 | SBC | |
Local Access+ HMO Network |
|||
Platinum Local Access+ HMO 0/20 OffEx |
01/01/2022 | Summary | SBC |
Platinum Local Access+ HMO 0/20 OffEx INF |
01/01/2022 | SBC | |
Platinum Local Access+ HMO 0/25 OffEx |
01/01/2022 | Summary | SBC |
Platinum Local Access+ HMO 0/25 OffEx INF |
01/01/2022 | SBC | |
Platinum Local Access+ HMO 0/30 OffEx |
01/01/2022 | Summary | SBC |
Platinum Local Access+ HMO 0/30 OffEx INF |
01/01/2022 | SBC | |
Gold Local Access+ HMO 0/30 OffEx |
01/01/2022 | Summary | SBC |
Gold Local Access+ HMO 0/30 OffEx INF |
01/01/2022 | SBC | |
Gold Local Access+ HMO 500/35 OffEx |
01/01/2022 | Summary | SBC |
Gold Local Access+ HMO 500/35 OffEx INF |
01/01/2022 | SBC | |
Gold Local Access+ HMO 1000/35 OffEx |
01/01/2022 | Summary | SBC |
Gold Local Access+ HMO 1000/35 OffEx INF |
01/01/2022 | SBC | |
Gold Local Access+ HMO 1500/35 OffEx |
01/01/2022 | Summary | SBC |
Gold Local Access+ HMO 1500/35 OffEx INF |
01/01/2022 | SBC | |
Silver Local Access+ HMO 2000/60 OffEx |
01/01/2022 | Summary | SBC |
Silver Local Access+ HMO 2000/60 OffEx INF |
01/01/2022 | SBC | |
Silver Local Access+ HMO 2750/65 OffEx |
01/01/2022 | Summary | SBC |
Silver Local Access+ HMO 2750/65 OffEx INF |
01/01/2022 | SBC | |
Trio HMO Network |
|||
Platinum Trio HMO 0/20 OffEx |
01/01/2022 | Summary | SBC |
Platinum Trio HMO 0/20 OffEx INF |
01/01/2022 | SBC | |
Platinum Trio HMO 0/25 OffEx |
01/01/2022 | Summary | SBC |
Platinum Trio HMO 0/25 OffEx INF |
01/01/2022 | SBC | |
Platinum Trio HMO 0/30 OffEx |
01/01/2022 | Summary | SBC |
Platinum Trio HMO 0/30 OffEx INF |
01/01/2022 | SBC | |
Gold Trio HMO 0/30 OffEx |
01/01/2022 | Summary | SBC |
Gold Trio HMO 0/30 OffEx INF |
01/01/2022 | SBC | |
Gold Trio HMO 500/35 OffEx |
01/01/2022 | Summary | SBC |
Gold Trio HMO 500/35 OffEx INF |
01/01/2022 | SBC | |
Gold Trio HMO 1000/35 OffEx |
01/01/2022 | Summary | SBC |
Gold Trio HMO 1000/35 OffEx INF |
01/01/2022 | SBC | |
Gold Trio HMO 1500/35 OffEx |
01/01/2022 | Summary | SBC |
Gold Trio HMO 1500/35 OffEx INF |
01/01/2022 | SBC | |
Silver Trio HMO 2000/60 OffEx |
01/01/2022 | Summary | SBC |
Silver Trio HMO 2000/60 OffEx INF |
01/01/2022 | SBC | |
Silver Trio HMO 2750/65 OffEx |
01/01/2022 | Summary | SBC |
Silver Trio HMO 2750/65 OffEx INF |
01/01/2022 | SBC | |
Bronze Trio HMO 7000/70 OffEx |
01/01/2022 | Summary | SBC |
Bronze Trio HMO 7000/70 OffEx INF |
01/01/2022 | SBC | |
2022 Medical PPO Off-Exchange Package |
|||
Full PPO Network |
|||
Platinum Full PPO 0/0 OffEx |
01/01/2022 | Summary | SBC |
Platinum Full PPO 0/0 OffEx INF |
01/01/2022 | SBC | |
Platinum Full PPO 0/10 OffEx |
01/01/2022 | Summary | SBC |
Platinum Full PPO 0/10 OffEx INF |
01/01/2022 | SBC | |
Platinum Full PPO 250/10 OffEx |
01/01/2022 | Summary | SBC |
Platinum Full PPO 250/10 OffEx INF |
01/01/2022 | SBC | |
Platinum Full PPO 250/15 OffEx |
01/01/2022 | Summary | SBC |
Platinum Full PPO 250/15 OffEx INF |
01/01/2022 | SBC | |
Gold Full PPO 0/25 OffEx |
01/01/2022 | Summary | SBC |
Gold Full PPO 0/25 OffEx INF |
01/01/2022 | SBC | |
Gold Full PPO 500/30 OffEx |
01/01/2022 | Summary | SBC |
Gold Full PPO 500/30 OffEx INF |
01/01/2022 | SBC | |
Gold Full PPO 750/30 OffEx |
01/01/2022 | Summary | SBC |
Gold Full PPO 750/30 OffEx INF |
01/01/2022 | SBC | |
Gold Full PPO 1000/35 OffEx |
01/01/2022 | Summary | SBC |
Gold Full PPO 1000/35 OffEx INF |
01/01/2022 | SBC | |
Gold Full PPO Savings 1750/15% HDHP PrevRx OffEx |
01/01/2022 | Summary | SBC |
Gold Full PPO Savings 1750/15% HDHP PrevRx OffEx INF |
01/01/2022 | SBC | |
Silver Full PPO 1800/45 OffEx |
01/01/2022 | Summary | SBC |
Silver Full PPO 1800/45 OffEx INF |
01/01/2022 | SBC | |
Silver Full PPO 2225/50 OffEx |
01/01/2022 | Summary | SBC |
Silver Full PPO 2225/50 OffEx INF |
01/01/2022 | SBC | |
Silver Full PPO 2400/55 OffEx |
01/01/2022 | Summary | SBC |
Silver Full PPO 2400/55 OffEx INF |
01/01/2022 | SBC | |
Silver Full PPO Savings 2100/25% OffEx |
01/01/2022 | Summary | SBC |
Silver Full PPO Savings 2100/25% OffEx INF |
01/01/2022 | SBC | |
Silver Full PPO Savings 2600/35% HDHP PrevRx OffEx |
01/01/2022 | Summary | SBC |
Silver Full PPO Savings 2600/35% HDHP PrevRx OffEx INF |
01/01/2022 | SBC | |
Bronze Full PPO 5500/65 OffEx |
01/01/2022 | Summary | SBC |
Bronze Full PPO 5500/65 OffEx INF |
01/01/2022 | SBC | |
Bronze Full PPO 6250/65 OffEx |
01/01/2022 | Summary | SBC |
Bronze Full PPO 6250/65 OffEx INF |
01/01/2022 | SBC | |
Bronze Full PPO 6500/70 OffEx |
01/01/2022 | Summary | SBC |
Bronze Full PPO 6500/70 OffEx INF |
01/01/2022 | SBC | |
Bronze Full PPO 6850/55 OffEx |
01/01/2022 | Summary | SBC |
Bronze Full PPO 6850/55 OffEx INF |
01/01/2022 | SBC | |
Bronze Full PPO 7500/65 OffEx |
01/01/2022 | Summary | SBC |
Bronze Full PPO 7500/65 OffEx INF |
01/01/2022 | SBC | |
Bronze Full PPO Savings 5700/40% OffEx |
01/01/2022 | Summary | SBC |
Bronze Full PPO Savings 5700/40% OffEx INF |
01/01/2022 | SBC | |
Bronze Full PPO Savings 7000 OffEx |
01/01/2022 | Summary | SBC |
Bronze Full PPO Savings 7000 OffEx INF |
01/01/2022 | SBC | |
Tandem PPO Network |
|||
Platinum Tandem PPO 0/0 OffEx |
01/01/2022 | Summary | SBC |
Platinum Tandem PPO 0/0 OffEx INF |
01/01/2022 | SBC | |
Platinum Tandem PPO 0/10 OffEx |
01/01/2022 | Summary | SBC |
Platinum Tandem PPO 0/10 OffEx INF |
01/01/2022 | SBC | |
Platinum Tandem PPO 250/10 OffEx |
01/01/2022 | Summary | SBC |
Platinum Tandem PPO 250/10 OffEx INF |
01/01/2022 | SBC | |
Platinum Tandem PPO 250/15 OffEx |
01/01/2022 | Summary | SBC |
Platinum Tandem PPO 250/15 OffEx INF |
01/01/2022 | SBC | |
Gold Tandem PPO 0/25 OffEx |
01/01/2022 | Summary | SBC |
Gold Tandem PPO 0/25 OffEx INF |
01/01/2022 | SBC | |
Gold Tandem PPO 500/30 OffEx |
01/01/2022 | Summary | SBC |
Gold Tandem PPO 500/30 OffEx INF |
01/01/2022 | SBC | |
Gold Tandem PPO 750/30 OffEx |
01/01/2022 | Summary | SBC |
Gold Tandem PPO 750/30 OffEx INF |
01/01/2022 | SBC | |
Gold Tandem PPO 1000/35 OffEx |
01/01/2022 | Summary | SBC |
Gold Tandem PPO 1000/35 OffEx INF |
01/01/2022 | SBC | |
Gold Tandem PPO Savings 1750/15% HDHP PrevRx OffEx |
01/01/2022 | Summary | SBC |
Gold Tandem PPO Savings 1750/15% HDHP PrevRx OffEx INF |
01/01/2022 | SBC | |
Silver Tandem PPO 1800/45 OffEx |
01/01/2022 | Summary | SBC |
Silver Tandem PPO 1800/45 OffEx INF |
01/01/2022 | SBC | |
Silver Tandem PPO 2225/50 OffEx |
01/01/2022 | Summary | SBC |
Silver Tandem PPO 2225/50 OffEx INF |
01/01/2022 | SBC | |
Silver Tandem PPO 2400/55 OffEx |
01/01/2022 | Summary | SBC |
Silver Tandem PPO 2400/55 OffEx INF |
01/01/2022 | SBC | |
Silver Tandem PPO Savings 2100/25% OffEx |
01/01/2022 | Summary | SBC |
Silver Tandem PPO Savings 2100/25% OffEx INF |
01/01/2022 | SBC | |
Silver Tandem PPO Savings 2600/35% HDHP PrevRx OffEx |
01/01/2022 | Summary | SBC |
Silver Tandem PPO Savings 2600/35% HDHP PrevRx OffEx INF |
01/01/2022 | SBC | |
Bronze Tandem PPO 5500/65 OffEx |
01/01/2022 | Summary | SBC |
Bronze Tandem PPO 5500/65 OffEx INF |
01/01/2022 | SBC | |
Bronze Tandem PPO 6250/65 OffEx |
01/01/2022 | Summary | SBC |
Bronze Tandem PPO 6250/65 OffEx INF |
01/01/2022 | SBC | |
Bronze Tandem PPO 6500/70 OffEx |
01/01/2022 | Summary | SBC |
Bronze Tandem PPO 6500/70 OffEx INF |
01/01/2022 | SBC | |
Bronze Tandem PPO 6850/55 OffEx |
01/01/2022 | Summary | SBC |
Bronze Tandem PPO 6850/55 OffEx INF |
01/01/2022 | SBC | |
Bronze Tandem PPO 7500/65 OffEx |
01/01/2022 | Summary | SBC |
Bronze Tandem PPO 7500/65 OffEx INF |
01/01/2022 | SBC | |
Bronze Tandem PPO Savings 5700/40% OffEx |
01/01/2022 | Summary | SBC |
Bronze Tandem PPO Savings 5700/40% OffEx INF |
01/01/2022 | SBC | |
Bronze Tandem PPO Savings 7000 OffEx |
01/01/2022 | Summary | SBC |
Bronze Tandem PPO Savings 7000 OffEx INF |
01/01/2022 | SBC | |
2022 Medical HMO Mirror Package |
|||
Blue Shield Trio Platinum 90 HMO 0/20 + Child Dental |
01/01/2022 | Summary | SBC |
Blue Shield Trio Platinum 90 HMO 0/20 + Child Dental INF |
01/01/2022 | SBC | |
Blue Shield Trio Gold 80 HMO 250/35 + Child Dental |
01/01/2022 | Summary | SBC |
Blue Shield Trio Gold 80 HMO 250/35 + Child Dental INF |
01/01/2022 | SBC | |
Blue Shield Trio Silver 70 HMO 2250/55 + Child Dental |
01/01/2022 | Summary | SBC |
Blue Shield Trio Silver 70 HMO 2250/55 + Child Dental INF |
01/01/2022 | SBC | |
2022 Medical PPO Mirror Package |
|||
Blue Shield Platinum 90 PPO 0/15 + Child Dental |
01/01/2022 | Summary | SBC |
Blue Shield Platinum 90 PPO 0/15 + Child Dental INF |
01/01/2022 | SBC | |
Blue Shield Gold 80 PPO 350/25 + Child Dental |
01/01/2022 | Summary | SBC |
Blue Shield Gold 80 PPO 350/25 + Child Dental INF |
01/01/2022 | SBC | |
Blue Shield Silver 70 PPO 2250/50 + Child Dental |
01/01/2022 | Summary | SBC |
Blue Shield Silver 70 PPO 2250/50 + Child Dental INF |
01/01/2022 | SBC | |
Blue Shield Bronze 60 PPO 6300/65 + Child Dental |
01/01/2022 | Summary | SBC |
Blue Shield Bronze 60 PPO 6300/65 + Child Dental INF |
01/01/2022 | SBC | |
2022 Infertility Riders |
|||
Infertility Rider for HMO Plans |
01/01/2022 | Summary | |
Infertility Rider for PPO Plans |
01/01/2022 | Summary | |
2021 Medical HMO Off-Exchange Package |
|||
Access+ HMO Network |
|||
Platinum Access+ HMO 0/20 OffEx |
01/01/2021 | Summary | SBC |
Platinum Access+ HMO 0/25 OffEx |
01/01/2021 | Summary | SBC |
Platinum Access+ HMO 0/30 OffEx |
01/01/2021 | Summary | SBC |
Gold Access+ HMO 0/30 OffEx |
01/01/2021 | Summary | SBC |
Gold Access+ HMO 500/35 OffEx |
01/01/2021 | Summary | SBC |
Gold Access+ HMO 1000/35 OffEx |
01/01/2021 | Summary | SBC |
Gold Access+ HMO 1500/35 OffEx |
01/01/2021 | Summary | SBC |
Silver Access+ HMO 2350/65 OffEx |
01/01/2021 | Summary | SBC |
Local Access+ HMO Network |
|||
Platinum Local Access+ HMO 0/20 OffEx |
01/01/2021 | Summary | SBC |
Platinum Local Access+ HMO 0/25 OffEx |
01/01/2021 | Summary | SBC |
Platinum Local Access+ HMO 0/30 OffEx |
01/01/2021 | Summary | SBC |
Gold Local Access+ HMO 0/30 OffEx |
01/01/2021 | Summary | SBC |
Gold Local Access+ HMO 500/35 OffEx |
01/01/2021 | Summary | SBC |
Gold Local Access+ HMO 1000/35 OffEx |
01/01/2021 | Summary | SBC |
Gold Local Access+ HMO 1500/35 OffEx |
01/01/2021 | Summary | SBC |
Silver Local Access+ HMO 2350/65 OffEx |
01/01/2021 | Summary | SBC |
Trio HMO Network |
|||
Platinum Trio HMO 0/20 OffEx |
01/01/2021 | Summary | SBC |
Platinum Trio HMO 0/25 OffEx |
01/01/2021 | Summary | SBC |
Platinum Trio HMO 0/30 OffEx |
01/01/2021 | Summary | SBC |
Gold Trio HMO 0/30 OffEx |
01/01/2021 | Summary | SBC |
Gold Trio HMO 500/35 OffEx |
01/01/2021 | Summary | SBC |
Gold Trio HMO 1000/35 OffEx |
01/01/2021 | Summary | SBC |
Gold Trio HMO 1500/35 OffEx |
01/01/2021 | Summary | SBC |
Silver Trio HMO 2350/65 OffEx |
01/01/2021 | Summary | SBC |
2021 Medical PPO Off-Exchange Package |
|||
Full PPO Network |
|||
Platinum Full PPO 0/0 OffEx |
01/01/2021 | Summary | SBC |
Platinum Full PPO 0/10 OffEx |
01/01/2021 | Summary | SBC |
Platinum Full PPO 250/10 OffEx |
01/01/2021 | Summary | SBC |
Platinum Full PPO 250/15 OffEx |
01/01/2021 | Summary | SBC |
Gold Full PPO 0/25 OffEx |
01/01/2021 | Summary | SBC |
Gold Full PPO 500/30 OffEx |
01/01/2021 | Summary | SBC |
Gold Full PPO 750/30 OffEx |
01/01/2021 | Summary | SBC |
Gold Full PPO 1200/35 OffEx |
01/01/2021 | Summary | SBC |
Gold Full PPO Savings 1750/15% OffEx |
01/01/2021 | Summary | SBC |
Silver Full PPO 1950/50 OffEx |
01/01/2021 | Summary | SBC |
Silver Full PPO 2225/50 OffEx |
04/01/2021 | Summary | SBC |
Silver Full PPO 2400/55 OffEx |
01/01/2021 | Summary | SBC |
Silver Full PPO Savings 2100/25% OffEx |
01/01/2021 | Summary | SBC |
Silver Full PPO Savings 2600/35% OffEx |
01/01/2021 | Summary | SBC |
Bronze Full PPO 6250/70 OffEx |
01/01/2021 | Summary | SBC |
Bronze Full PPO 6850/65 OffEx |
01/01/2021 | Summary | SBC |
Bronze Full PPO 7500/50 OffEx |
01/01/2021 | Summary | SBC |
Bronze Full PPO Savings 5700/40% OffEx |
01/01/2021 | Summary | SBC |
Bronze Full PPO Savings 7000 OffEx |
01/01/2021 | Summary | SBC |
Tandem PPO Network |
|||
Platinum Tandem PPO 0/0 OffEx |
01/01/2021 | Summary | SBC |
Platinum Tandem PPO 0/10 OffEx |
01/01/2021 | Summary | SBC |
Platinum Tandem PPO 250/10 OffEx |
01/01/2021 | Summary | SBC |
Platinum Tandem PPO 250/15 OffEx |
01/01/2021 | Summary | SBC |
Gold Tandem PPO 0/25 OffEx |
01/01/2021 | Summary | SBC |
Gold Tandem PPO 500/30 OffEx |
01/01/2021 | Summary | SBC |
Gold Tandem PPO 750/30 OffEx |
01/01/2021 | Summary | SBC |
Gold Tandem PPO 1200/35 OffEx |
01/01/2021 | Summary | SBC |
Gold Tandem PPO Savings 1750/15% OffEx |
01/01/2021 | Summary | SBC |
Silver Tandem PPO 1950/50 OffEx |
01/01/2021 | Summary | SBC |
Silver Tandem PPO 2225/50 OffEx |
04/01/2021 | Summary | SBC |
Silver Tandem PPO 2400/55 OffEx |
01/01/2021 | Summary | SBC |
Silver Tandem PPO Savings 2100/25% OffEx |
01/01/2021 | Summary | SBC |
Silver Tandem PPO Savings 2600/35% OffEx |
01/01/2021 | Summary | SBC |
Bronze Tandem PPO 6250/70 OffEx |
01/01/2021 | Summary | SBC |
Bronze Tandem PPO 6850/65 OffEx |
01/01/2021 | Summary | SBC |
Bronze Tandem PPO 7500/50 OffEx |
01/01/2021 | Summary | SBC |
Bronze Tandem PPO Savings 5700/40% OffEx |
01/01/2021 | Summary | SBC |
Bronze Tandem PPO Savings 7000 OffEx |
01/01/2021 | Summary | SBC |
2021 Medical HMO Mirror Package |
|||
Blue Shield Trio Platinum 90 HMO 0/20 + Child Dental |
01/01/2021 | Summary | SBC |
Blue Shield Trio Platinum 90 HMO 0/20 + Child Dental INF (with Infertility Rider) |
01/01/2021 | SBC | |
Blue Shield Trio Gold 80 HMO 250/35 + Child Dental |
01/01/2021 | Summary | SBC |
Blue Shield Trio Gold 80 HMO 250/35 + Child Dental INF (with Infertility Rider) |
01/01/2021 | SBC | |
Blue Shield Trio Silver 70 HMO 2250/55 + Child Dental |
01/01/2021 | Summary | SBC |
Blue Shield Trio Silver 70 HMO 2250/55 + Child Dental INF (with Infertility Rider) |
01/01/2021 | SBC | |
2021 Medical PPO Mirror Package |
|||
Blue Shield Platinum 90 PPO 0/15 + Child Dental |
01/01/2021 | Summary | SBC |
Blue Shield Platinum 90 PPO 0/15 + Child Dental INF (with Infertility Rider) |
01/01/2021 | SBC | |
Blue Shield Gold 80 PPO 350/25 + Child Dental |
01/01/2021 | Summary | SBC |
Blue Shield Gold 80 PPO 350/25 + Child Dental INF (with Infertility Rider) |
01/01/2021 | SBC | |
Blue Shield Silver 70 PPO 2250/50 + Child Dental |
01/01/2021 | Summary | SBC |
Blue Shield Silver 70 PPO 2250/50 + Child Dental INF (with Infertility Rider) |
01/01/2021 | SBC | |
Blue Shield Bronze 60 PPO 6300/65 + Child Dental |
01/01/2021 | Summary | SBC |
Blue Shield Bronze 60 PPO 6300/65 + Child Dental INF (with Infertility Rider) |
01/01/2021 | SBC | |
2021 Infertility Riders |
|||
Infertility Rider for HMO Plans |
01/01/2021 | Summary | |
Infertility Rider for PPO Plans |
01/01/2021 | Summary | |
2021 Dental Plans |
|||
DHMO Plans |
|||
Dental HMO Basic |
01/01/2021 | Summary | |
Dental HMO Standard |
01/01/2021 | Summary | |
Dental HMO Plus |
01/01/2021 | Summary | |
Dental HMO Deluxe |
01/01/2021 | Summary | |
Dental HMO Voluntary |
01/01/2021 | Summary | |
Dental PPO |
|||
DPPO Plans with ADV |
|||
Smile Plus Gold 50/1500/Ortho/U80/ADV |
01/01/2021 | Summary | |
Smile Plus Gold 50/1500/Ortho/U90/ADV |
01/01/2021 | Summary | |
Smile Plus Gold 50/1500/No Ortho/U90/ADV |
01/01/2021 | Summary | |
Smile Plus Gold 50/2500/Ortho/U90/ADV |
01/01/2021 | Summary | |
Smile Plus Gold 50/2500/No Ortho/U90/ADV |
01/01/2021 | Summary | |
DPPO Plans without ADV |
|||
Ultimate Dental Plus PPO for Small Business 50/2000/Ortho/MAC/NR |
01/01/2021 | Summary | |
Ultimate Dental PPO for Small Business 50/2000/No Ortho/MAC/NR |
01/01/2021 | Summary | |
Ultimate Dental PPO for Small Business 50/2000/Lifetime Ortho/U90 |
01/01/2021 | Summary | |
Ultimate Dental PPO for Small Business 50/2000/No Ortho/U90 |
01/01/2021 | Summary | |
Ultimate Dental PPO for Small Business 50/2000/No Ortho/U80 |
01/01/2021 | Summary | |
Smile Deluxe Plus 2000 50/2000/Ortho/MAC/NR |
01/01/2021 | Summary | |
Smile Deluxe Gold 50/1500/Ortho/U85/NR |
01/01/2021 | Summary | |
Smile Deluxe 2000 50/2000/No Ortho/MAC/NR |
01/01/2021 | Summary | |
Smile Deluxe 50/1500/Ortho/MAC/NR |
01/01/2021 | Summary | |
Smile Plus Gold 50/1500/Ortho/U85/NR |
01/01/2021 | Summary | |
Smile Plus Gold 50/1500/Ortho/U80 |
01/01/2021 | Summary | |
Smile Plus Gold 50/1500/No Ortho/U80 |
01/01/2021 | Summary | |
Smile Plus 50/1500/Ortho/MAC/NR |
01/01/2021 | Summary | |
Smile Plus 50/1500/No Ortho/MAC |
01/01/2021 | Summary | |
Smile Plus 50/1500/No Ortho/MAC/WP |
01/01/2021 | Summary | |
Smile 50/1500/No Ortho/MAC/NR |
01/01/2021 | Summary | |
Smile Value 50/1500/No Ortho/MAC/NR |
01/01/2021 | Summary | |
Smile Basic 50/1000/Ortho/U85 |
01/01/2021 | Summary | |
Smile Basic 50/1000/No Ortho/MAC |
01/01/2021 | Summary | |
Smile Basic 75/1000/No Ortho/MAC/NR |
01/01/2021 | Summary | |
Smile Basic Voluntary 50/1500/Ortho/U80 |
01/01/2021 | Summary | |
Smile Basic Voluntary 50/1000/No Ortho/U80 |
01/01/2021 | Summary | |
Smile Basic Voluntary 50/1000/No Ortho/MAC |
01/01/2021 | Summary | |
Smile Basic Voluntary 75/1000/No Ortho/MAC/NR |
01/01/2021 | Summary | |
Closed Dental PPO Plans with Rollover Rewards - Available to Renewing Groups Only |
|||
Ultimate Dental Plus PPO for Small Business 50/2000/Ortho/MAC |
01/01/2021 | Summary | |
Ultimate Dental PPO for Small Business 50/2000/No Ortho/MAC |
01/01/2021 | Summary | |
Smile Deluxe Plus 2000 50/2000/Ortho/MAC |
01/01/2021 | Summary | |
Smile Deluxe Gold 50/1500/Ortho/U85 |
01/01/2021 | Summary | |
Smile Deluxe 2000 50/2000/No Ortho/MAC |
01/01/2021 | Summary | |
Smile Deluxe 50/1500/Ortho/MAC |
01/01/2021 | Summary | |
Smile Plus Gold 50/1500 Ortho/U85 |
01/01/2021 | Summary | |
Smile Plus 50/1500/Ortho/MAC |
01/01/2021 | Summary | |
Smile 50/1500/No Ortho/MAC |
01/01/2021 | Summary | |
Smile Value 50/1500/No Ortho/MAC |
01/01/2021 | Summary | |
Smile Basic 75/1000/No Ortho/MAC |
01/01/2021 | Summary | |
Smile Basic Voluntary 75/1000/No Ortho/MAC |
01/01/2021 | Summary | |
Closed Dental INO Plans with Rollover Rewards - Available to Renewing Groups Only |
|||
Smile INO Dental Plan 50/1500/Endo-Perio 80%/No Ortho |
01/01/2021 | Summary | |
Smile INO Dental Plan 50/1500/Endo-Perio 80%/Ortho |
01/01/2021 | Summary | |
Smile INO Dental Plan 50/2500/Endo-Perio 80%/No Ortho |
01/01/2021 | Summary | |
Smile INO Dental Plan 50/2500/Endo-Perio 80%/Ortho |
01/01/2021 | Summary | |
Smile INO Dental Voluntary Plan 50/1500/Endo-Perio 50%/No Ortho |
01/01/2021 | Summary | |
Smile INO Dental Voluntary Plan 50/1500/Endo-Perio 50%/Ortho |
01/01/2021 | Summary | |
Smile INO Dental Voluntary Plan 50/2500/Endo-Perio 50%/No Ortho |
01/01/2021 | Summary | |
Smile INO Dental Voluntary Plan 50/2500/Endo-Perio 50%/Ortho |
01/01/2021 | Summary | |
2021 Vision Plans |
|||
Ultimate Vision Plans (12/12/12) |
|||
Ultimate Vision 0/0/120 |
01/01/2021 | Summary | |
Ultimate Vision 0/0/150 |
01/01/2021 | Summary | |
Ultimate Vision 10/25/120 |
01/01/2021 | Summary | |
Ultimate Vision 10/25/150 |
01/01/2021 | Summary | |
Ultimate Vision Plus 0/0/150/120 |
01/01/2021 | Summary | |
Ultimate Vision Plus 10/25/150/120 |
01/01/2021 | Summary | |
Ultimate Vision Voluntary 10/25/150 |
01/01/2021 | Summary | |
Preferred Vision Plans (12/12/24) |
|||
Preferred Vision 0/0/120 |
01/01/2021 | Summary | |
Preferred Vision 0/0/150 |
01/01/2021 | Summary | |
Preferred Vision 10/25/120 |
01/01/2021 | Summary | |
Preferred Vision 10/25/150 |
01/01/2021 | Summary | |
Preferred Vision Plus 0/0/150/120 |
01/01/2021 | Summary | |
Preferred Vision Plus 10/25/150/120 |
01/01/2021 | Summary | |
Preferred Vision Voluntary 10/25/120 |
01/01/2021 | Summary | |
Basic Vision Plans (12/24/24) |
|||
Basic Vision 0/0/120 |
01/01/2021 | Summary |
Form Name | Effective Date | Download Form |
---|---|---|
General Information |
||
Small Business Medical Sales Guide 10.23 |
10/01/2023 | Download |
Small Business Medical Sales Guide 7.23 |
07/01/2023 | Download |
Small Business Medical Sales Guide 4.23 |
04/01/2023 | Download |
Underwriting Guidelines 7.23 |
07/01/2023 | Download |
Underwriting Guidelines 1.23 |
01/01/2023 | Download |
How to Print or Order your ID Card |
01/01/2022 | Download |
Online and Mobile Tools |
09/01/2023 | Download |
Pediatric Dental & Vision Flyer |
01/01/2022 | Download |
Pediatric Dental & Vision FAQ |
01/01/2022 | Download |
Premium Only Plan by HealthEquity |
01/01/2022 | Download |
Producer Agreement 2023 |
01/01/2023 | Download |
Relaxed Participation Guidelines through 12.23 Effective Date |
01/01/2023 | Download |
Specialty Bundle & Save Flyer |
01/01/2022 | Download |
Specialty Quick Facts |
01/01/2022 | Download |
Specialty Sales Guide 10.23 |
10/01/2023 | Download |
Specialty Sales Guide 7.23 |
07/01/2023 | Download |
Specialty Sales Guide 4.23 |
04/01/2023 | Download |
Why Blue Shield of California Employer Brochure |
01/01/2022 | Download |
Medical |
||
Medical Plans at a Glance 7.23 |
07/01/2023 | Download |
Medical Plans at a Glance 1.23 (Revised) |
01/01/2023 | Download |
Medical Plans Cheat Sheet 7.23 |
07/01/2023 | Download |
Medical Plans Cheat Sheet 1.23 (Revised) |
01/01/2023 | Download |
Accessing Care - Care When You Need It Flyer |
09/01/2023 | Download |
BlueCard and Away from Home Care for HMO Members Flyer |
09/01/2023 | Download |
Blue Card Program for Care Outside California for PPO Members |
01/01/2022 | Download |
Epic Hearing Discounts |
09/01/2023 | Download |
Fitness Your Way Flyer |
09/01/2023 | Download |
LifeReferrals 24/7 Flyer |
01/01/2022 | Download |
LifeReferrals Employer Flyer |
01/01/2022 | Download |
LifeReferrals Critical Incident Flyer |
01/01/2022 | Download |
LifeReferrals Workplace Support Flyer |
01/01/2022 | Download |
Mail Service Prescriptions Flyer |
09/01/2023 | Download |
Mail Service Order Form |
01/01/2022 | Download |
Maven Maternity Flyer |
09/01/2023 | Download |
MyStrength for Trio & Tandem Flyer |
01/01/2022 | Download |
NurseHelp Employee Flyer |
01/01/2022 | Download |
Online Provider Search Instructions |
01/01/2022 | Download |
Standard Prescription Drug Formulary 11.22 |
07/01/2023 | Download |
Specialty Drug List for Standard Drug Formulary |
07/01/2023 | Download |
Preventive Health Guidelines |
01/01/2022 | Download |
Shield Concierge for Tandem Members |
08/01/2022 | Download |
Shield Concierge for Trio Members |
08/01/2022 | Download |
Tandem PPO Member Flyer |
01/01/2022 | Download |
Teladoc Flyer |
09/01/2023 | Download |
Spectrum Tiered Pharmacy Network Directory |
07/01/2023 | Download |
Spectrum Tiered Pharmacy Network Flyer |
07/01/2023 | Download |
Total Health and Wellness - Programs & Services for Blue Shield Members |
09/01/2023 | Download |
Treatment Cost Estimator PPO Member Flyer |
01/01/2022 | Download |
Trio HMO Brochure |
06/01/2022 | Download |
Trio HMO Network Brochure |
01/01/2022 | Download |
Urgent Care Flyer |
01/01/2022 | Download |
Vaccines at Retail Pharmacies |
09/01/2023 | Download |
Wellness Discounts for Blue Shield Members |
09/01/2023 | Download |
Wellvolution Flyer |
09/01/2023 | Download |
Wellvolution Ginger Flyer |
09/01/2023 | Download |
Wellvolution Headspace Flyer |
09/01/2023 | Download |
Why Switch to Tandem Flyer |
01/01/2022 | Download |
Why Switch to Trio Flyer |
01/01/2022 | Download |
Women's Preventive Health |
01/01/2022 | Download |
Dental |
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Caries Risk Management & Assessment |
01/01/2022 | Download |
Dental Implant FAQ |
01/01/2022 | Download |
Dental Network Map |
01/01/2022 | Download |
Find a Dental or Vision Provider of Your Choice |
01/01/2022 | Download |
Dental Smile Rollover Rewards Program (not available on new DPPO plans as of 4.1.19) |
01/01/2021 | Download |
Dentist Nomination Form |
08/01/2022 | Download |
Guide to Managing your Dental Plan Online |
01/01/2022 | Download |
Member Guide to Orthodontic Coverage |
01/01/2022 | Download |
Vision |
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Managing Your Vision Plan Online |
01/01/2022 | Download |
Vision Network at a Glance |
01/01/2021 | Download |
Find a Dental or Vision Provider of Your Choice |
01/01/2022 | Download |
Vision Plan Information Card for CA Members |
01/01/2022 | Download |
Vision Plan Information Card for Out-of-State Members |
01/01/2022 | Download |
Life |
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Basic Life/AD&D Quick Match Program Guidelines |
01/01/2022 | Download |
LifeReferrals 24/7 - Beneficiary Assistance Program |
08/01/2022 | Download |
Travel Assistance Program Brochure |
08/01/2022 | Download |
Form Name | Effective Date | Download Form |
---|---|---|
Rate Tables - All Rating Areas [effective 10/1/2023] |
10/01/2023 | Download |
Rate Tables - All Rating Areas [effective 7/1/2023] |
07/01/2023 | Download |
Rate Tables - All Rating Areas [effective 4/1/2023] |
04/01/2023 | Download |
Rate Tables - All Rating Areas [effective 1/1/2023] |
01/01/2023 | Download |