Blue Shield of California

As a not-for-profit health plan, Blue Shield is guided by our mission and values, which encourage innovation and enable us to be a catalyst for constructive change. Our mission and values are embodied in our proposal to guarantee health coverage for all Californians, the first time a major health plan has called for universal coverage.

Provider Finder

 

Form Name Effective Date Download Form
New Group Submission
New Group Submission Checklist 1.22
01/01/2022 Download
Employer Application 10.22 Effective Dates
10/01/2022 Download
Employer Application 1.23 Effective Dates
01/01/2023 Download
Small Business Owner Eligibility Statement
01/01/2022 Download
Small Group Check by Fax Form
01/01/2022 Download
Start-up Spin-off Companies Small Business Eligibility Statement
01/01/2022 Download
In Force Group Forms
Employer Group Change Request Form 10.22 Effective Dates
10/01/2022 Download
Employer Group Change Request Form 1.23 Effective Dates
01/01/2023 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
CMS Reporting Form
01/01/2022 Download
Renewal Guide 2022
01/01/2022 Download
Administration
2022 Group Administrator's Guide
01/01/2022 Download
Employer Connection Plus FAQ & QuickStart Guide
01/01/2022 Download
Employer Connection Plus Online Bill Payment FAQ
01/01/2022 Download
Employer Connection Plus Open Enrollment Guide
01/01/2022 Download
Form Name Effective Date Download Form
Enrollment and Change Forms
Small Group Employee Enrollment Form 10.22 Effective Dates
10/01/2022 Download
Small Group Employee Enrollment Form 1.23 Effective Dates
06/01/2022 Download
Refusal of Coverage Form 10.22
10/01/2022 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 10.22 Effective Dates
10/01/2022 Download
Subscriber Change Request Form 1.23 Effective Dates
01/01/2023 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
2023 Medical HMO Mirror Package
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
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 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
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
Sales Guide 7.22
07/01/2022 Download
Sales Guide 1.23
01/01/2023 Download
Underwriting Guidelines 7.22
07/01/2022 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
01/01/2022 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
Relaxed Participation Guidelines through 12.22 Effective Date
01/01/2022 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 7.22
07/01/2022 Download
Specialty Sales Guide 1.23
01/01/2023 Download
Why Blue Shield of California Employer Brochure
01/01/2022 Download
Medical
Medical Plans at a Glance 1.22
01/01/2022 Download
Medical Plans Cheat Sheet 1.22
06/01/2022 Download
Medical Plans at a Glance 1.23
01/01/2023 Download
Medical Plans Cheat Sheet 1.23
01/01/2023 Download
Away from Home Care for HMO Members Flyer
01/01/2022 Download
Blue Card Program for Care Outside California for PPO Members
01/01/2022 Download
Epic Hearing Discounts
01/01/2022 Download
Fitness Your Way Flyer
01/01/2022 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
01/01/2022 Download
Mail Service Order Form
01/01/2022 Download
Maven Maternity Flyer
01/01/2022 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 1.22
01/01/2022 Download
Specialty Drug List for Standard Drug Formulary
04/01/2022 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
05/01/2022 Download
Spectrum Level A Tiered Pharmacy Network Directory
08/01/2022 Download
Spectrum Tiered Pharmacy Network Flyer - Trio & Tandem Members
08/01/2022 Download
Total Health and Wellness - Programs & Services for Blue Shield Members
06/01/2022 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
01/01/2022 Download
Wellness Discounts for Blue Shield Members
01/01/2022 Download
Wellvolution Flyer
01/01/2022 Download
Wellvolution Headspace Flyer
01/01/2022 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 10/1/2022]
10/01/2022 Download
Rate Tables - All Rating Areas [effective 1/1/2023]
01/01/2023 Download