Blue Shield of California

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
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
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
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

Blue Shield of California

Provider Finder