| Form Name | Effective Date | Download Form |
|---|---|---|
|
New Group Submission |
||
|
New Group Submission Checklist |
01/01/2019 | Download |
|
Express Enrollment Guidelines |
01/01/2019 | Download |
|
Employer Application 1.19 to 3.19 Effective Dates |
01/01/2019 | Download |
|
Employer Application 4.19 to 6.19 Effective Dates |
04/01/2019 | Download |
|
Employer Application 7.19 to 9.19 Effective Dates |
07/01/2019 | Download |
|
Employer Application 10.19 to 12.19 Effective Dates |
10/01/2019 | Download |
|
Eligibility/Participation Attestation (for groups with 5+ enrolling employees) |
01/01/2019 | Download |
|
Sole Proprietor, Partner, or Corporate Officer Statement |
01/01/2019 | Download |
|
Small Group Check by Fax Form |
01/01/2019 | Download |
|
In Force Group Forms |
||
|
Employer Request For Contract Change Form 1.19 to 3.19 Effective Dates |
01/01/2019 | Download |
|
Employer Request For Contract Change Form 4.19 to 6.19 Effective Dates |
04/01/2019 | Download |
|
Employer Request For Contract Change Form 7.19 to 9.19 Effective Dates |
07/01/2019 | Download |
|
Employer Request For Contract Change Form 10.19 to 12.19 Effective Dates |
10/01/2019 | Download |
|
Blue Shield Multiple Subscriber Change Spreadsheet |
01/01/2019 | Download |
|
Employee Cancellation Transmittal Request |
01/01/2019 | Download |
|
Employer Notification of Qualifying Events under Cal-COBRA |
01/01/2019 | Download |
|
CMS Reporting Form |
01/01/2019 | Download |
|
Group Information Update Form |
01/01/2019 | Download |
|
Administration |
||
|
2019 Group Administrator's Guide |
01/01/2019 | Download |
|
2018 Group Administrator's Guide |
01/01/2018 | Download |
|
Employer Connection Plus FAQ & QuickStart Guide |
01/01/2019 | Download |
|
Employer Connection Plus Online Bill Payment FAQ |
01/01/2019 | Download |
|
Employer Connection Plus Open Enrollment Guide |
01/01/2019 | Download |
| Form Name | Effective Date | Download Form |
|---|---|---|
|
Enrollment and Change Forms |
||
|
Small Group Employee Enrollment Form 1.19 to 3.19 Effective Dates |
01/01/2019 | Download |
|
Small Group Employee Enrollment Form 4.19 to 6.19 Effective Dates |
04/01/2019 | Download |
|
Small Group Employee Enrollment Form 7.19 to 9.19 Effective Dates |
07/01/2019 | Download |
|
Small Group Employee Enrollment Form 10.19 to 12.19 Effective Dates |
10/01/2019 | Download |
|
Refusal of Coverage Form |
01/01/2019 | Download |
|
Continuity of Care Program Brochure |
01/01/2019 | Download |
|
Continuity of Care Services Request Form |
01/01/2019 | Download |
|
Declaration of Disability for Over-Age Dependent Child |
01/01/2019 | Download |
|
Prior Carrier Deductible Instructions and Form |
01/01/2019 | Download |
|
Subscriber Change Request Form 1.19 to 3.19 Effective Dates |
01/01/2019 | Download |
|
Subscriber Change Request Form 4.19 to 6.19 Effective Dates |
04/01/2019 | Download |
|
Subscriber Change Request Form 7.19 to 9.19 Effective Dates |
07/01/2019 | Download |
|
Subscriber Change Request Form 10.19 to 12.19 Effective Dates |
10/01/2019 | Download |
|
COBRA and Cal-COBRA Forms |
||
|
COBRA Continuation of Coverage Application |
01/01/2019 | Download |
|
Continuing Group Coverage After Federal COBRA Cal-COBRA Election Form |
01/01/2019 | Download |
|
Cal-COBRA Take-Over Form |
01/01/2019 | Download |
|
Cal-COBRA Election Form |
01/01/2019 | Download |
|
Cal-COBRA Dental Election Form |
01/01/2019 | Download |
|
Claim Forms |
||
|
Authorization for the Use or Disclosure of Health Information |
01/01/2019 | Download |
|
Medical Claim Form |
01/01/2019 | Download |
|
Medical Claim Form - Blue Shield Life |
01/01/2019 | Download |
|
Pharmacy Reimbursement Form |
01/01/2019 | Download |
|
Global Care International Claim Form |
01/01/2019 | Download |
|
Dental Claim Form |
01/01/2019 | Download |
|
Vision Claim Form |
01/01/2019 | Download |
|
Proof of Death Form - Group Life |
01/01/2019 | Download |
|
Dismemberment Claim Form - Group Life |
01/01/2019 | Download |
|
Accelerated Death Benefit Claim Form - Group Life |
01/01/2019 | Download |
|
Waiver of Premium Claim Form - Group Life |
01/01/2019 | Download |
| Form Name | Effective Date | Download Form | |
|---|---|---|---|
|
2019 Medical HMO Off-Exchange Package |
|||
|
Access+ HMO Network |
|||
|
Platinum Access+ HMO 0/20 OffEx |
01/01/2019 | Summary | SBC |
|
Platinum Access+ HMO 0/20 OffEx INF (with Infertility Rider) |
01/01/2019 | SBC | |
|
Platinum Access+ HMO 0/25 OffEx |
01/01/2019 | Summary | SBC |
|
Platinum Access+ HMO 0/25 OffEx INF (with Infertility Rider) |
01/01/2019 | SBC | |
|
Platinum Access+ HMO 0/30 OffEx |
01/01/2019 | Summary | SBC |
|
Platinum Access+ HMO 0/30 OffEx INF (with Infertility Rider) |
01/01/2019 | SBC | |
|
Gold Access+ HMO 0/30 OffEx |
01/01/2019 | Summary | SBC |
|
Gold Access+ HMO 0/30 OffEx INF (with Infertility Rider) |
01/01/2019 | SBC | |
|
Gold Access+ HMO 500/35 OffEx |
01/01/2019 | Summary | SBC |
|
Gold Access+ HMO 500/35 OffEx INF (with Infertility Rider) |
01/01/2019 | SBC | |
|
Gold Access+ HMO 1500/35 OffEx |
01/01/2019 | Summary | SBC |
|
Gold Access+ HMO 1500/35 OffEx INF (with Infertility Rider) |
01/01/2019 | SBC | |
|
Silver Access+ HMO 1975/55 OffEx |
01/01/2019 | Summary | SBC |
|
Silver Access+ HMO 1975/55 OffEx INF (with Infertility Rider) |
01/01/2019 | SBC | |
|
Local Access+ HMO Network |
|||
|
Platinum Local Access+ HMO 0/20 OffEx |
01/01/2019 | Summary | SBC |
|
Platinum Local Access+ HMO 0/20 OffEx INF (with Infertility Rider) |
01/01/2019 | SBC | |
|
Platinum Local Access+ HMO 0/25 OffEx |
01/01/2019 | Summary | SBC |
|
Platinum Local Access+ HMO 0/25 OffEx INF (with Infertility Rider) |
01/01/2019 | SBC | |
|
Platinum Local Access+ HMO 0/30 OffEx |
01/01/2019 | Summary | SBC |
|
Platinum Local Access+ HMO 0/30 OffEx INF (with Infertility Rider) |
01/01/2019 | SBC | |
|
Gold Local Access+ HMO 0/30 OffEx |
01/01/2019 | Summary | SBC |
|
Gold Local Access+ HMO 0/30 OffEx INF (with Infertility Rider) |
01/01/2019 | SBC | |
|
Gold Local Access+ HMO 500/35 OffEx |
01/01/2019 | Summary | SBC |
|
Gold Local Access+ HMO 500/35 OffEx INF (with Infertility Rider) |
01/01/2019 | SBC | |
|
Gold Local Access+ HMO 1500/35 OffEx |
01/01/2019 | Summary | SBC |
|
Gold Local Access+ HMO 1500/35 OffEx INF (with Infertility Rider) |
01/01/2019 | SBC | |
|
Silver Local Access+ HMO 1975/55 OffEx |
01/01/2019 | Summary | SBC |
|
Silver Local Access+ HMO 1975/55 OffEx INF (with Infertility Rider) |
01/01/2019 | SBC | |
|
Trio HMO Network |
|||
|
Platinum Trio HMO 0/20 OffEx |
01/01/2019 | Summary | SBC |
|
Platinum Trio HMO 0/20 OffEx INF (with Infertility Rider) |
01/01/2019 | SBC | |
|
Platinum Trio HMO 0/25 OffEx |
01/01/2019 | Summary | SBC |
|
Platinum Trio HMO 0/25 OffEx INF (with Infertility Rider) |
01/01/2019 | SBC | |
|
Platinum Trio HMO 0/30 OffEx |
01/01/2019 | Summary | SBC |
|
Platinum Trio HMO 0/30 OffEx INF (with Infertility Rider) |
01/01/2019 | SBC | |
|
Gold Trio HMO 0/30 OffEx |
01/01/2019 | Summary | SBC |
|
Gold Trio HMO 0/30 OffEx INF (with Infertility Rider) |
01/01/2019 | SBC | |
|
Gold Trio HMO 500/35 OffEx |
01/01/2019 | Summary | SBC |
|
Gold Trio HMO 500/35 OffEx INF (with Infertility Rider) |
01/01/2019 | SBC | |
|
Gold Trio HMO 1500/35 OffEx |
01/01/2019 | Summary | SBC |
|
Gold Trio HMO 1500/35 OffEx INF (with Infertility Rider) |
01/01/2019 | SBC | |
|
Silver Trio HMO 1975/55 OffEx |
01/01/2019 | Summary | SBC |
|
Silver Trio HMO 1975/55 OffEx INF (with Infertility Rider) |
01/01/2019 | SBC | |
|
2019 Medical PPO Off-Exchange Package |
|||
|
Full PPO Network |
|||
|
Platinum Full PPO 0/10 OffEx |
01/01/2019 | Summary | SBC |
|
Platinum Full PPO 0/10 OffEx INF (with Infertility Rider) |
01/01/2019 | SBC | |
|
Platinum Full PPO 250/15 OffEx |
01/01/2019 | Summary | SBC |
|
Platinum Full PPO 250/15 OffEx INF (with Infertility Rider) |
01/01/2019 | SBC | |
|
Gold Full PPO 0/20 OffEx |
01/01/2019 | Summary | SBC |
|
Gold Full PPO 0/20 OffEx INF (with Infertility Rider) |
01/01/2019 | SBC | |
|
Gold Full PPO 500/30 OffEx |
01/01/2019 | Summary | SBC |
|
Gold Full PPO 500/30 OffEx INF (with Infertility Rider) |
01/01/2019 | SBC | |
|
Gold Full PPO 750/30 OffEx |
01/01/2019 | Summary | SBC |
|
Gold Full PPO 750/30 OffEx INF (with Infertility Rider) |
01/01/2019 | SBC | |
|
Gold Full PPO 1200/35 OffEx |
01/01/2019 | Summary | SBC |
|
Gold Full PPO 1200/35 OffEx INF (with Infertility Rider) |
01/01/2019 | SBC | |
|
Silver Full PPO 1700/55 OffEx |
01/01/2019 | Summary | SBC |
|
Silver Full PPO 1700/55 OffEx INF (with Infertility Rider) |
01/01/2019 | SBC | |
|
Silver Full PPO 2000/45 OffEx |
01/01/2019 | Summary | SBC |
|
Silver Full PPO 2000/45 OffEx INF (with Infertility Rider) |
01/01/2019 | SBC | |
|
Silver Full PPO Savings 2000/20% OffEx |
01/01/2019 | Summary | SBC |
|
Silver Full PPO Savings 2000/20% OffEx INF (with Infertility Rider) |
01/01/2019 | SBC | |
|
Bronze Full PPO 4500/70 OffEx |
07/01/2019 | Summary | SBC |
|
Bronze Full PPO 4500/70 OffEx INF (with Infertility Rider) |
07/01/2019 | SBC | |
|
Bronze Full PPO 6000/65 OffEx |
07/01/2019 | Summary | SBC |
|
Bronze Full PPO 6000/65 OffEx INF (with Infertility Rider) |
07/01/2019 | SBC | |
|
Bronze Full PPO 6500/50% OffEx |
01/01/2019 | Summary | SBC |
|
Bronze Full PPO 6500/50% OffEx INF (with Infertility Rider) |
01/01/2019 | SBC | |
|
Bronze Full PPO Savings 5300/40% OffEx |
01/01/2019 | Summary | SBC |
|
Bronze Full PPO Savings 5300/40% OffEx INF (with Infertility Rider) |
01/01/2019 | SBC | |
|
Bronze Full PPO Savings 6650 OffEx |
01/01/2019 | Summary | SBC |
|
Bronze Full PPO Savings 6650 OffEx INF (with Infertility Rider) |
01/01/2019 | SBC | |
|
Tandem PPO Network |
|||
|
Platinum Tandem PPO 0/10 OffEx |
01/01/2019 | Summary | SBC |
|
Platinum Tandem PPO 0/10 OffEx INF (with Infertility Rider) |
01/01/2019 | SBC | |
|
Platinum Tandem PPO 250/15 OffEx |
01/01/2019 | Summary | SBC |
|
Platinum Tandem PPO 250/15 OffEx INF (with Infertility Rider) |
01/01/2019 | SBC | |
|
Gold Tandem PPO 750/30 OffEx |
01/01/2019 | Summary | SBC |
|
Gold Tandem PPO 750/30 OffEx INF (with Infertility Rider) |
01/01/2019 | SBC | |
|
Silver Tandem PPO 1700/55 OffEx |
01/01/2019 | Summary | SBC |
|
Silver Tandem PPO 1700/55 OffEx INF (with Infertility Rider) |
01/01/2019 | SBC | |
|
Silver Tandem PPO 2000/45 OffEx |
01/01/2019 | Summary | SBC |
|
Silver Tandem PPO 2000/45 OffEx INF (with Infertility Rider) |
01/01/2019 | SBC | |
|
Silver Tandem PPO Savings 2000/20% OffEx |
01/01/2019 | Summary | SBC |
|
Silver Tandem PPO Savings 2000/20% OffEx INF (with Infertility Rider) |
01/01/2019 | SBC | |
|
Bronze Tandem PPO 4500/70 OffEx |
07/01/2019 | Summary | SBC |
|
Bronze Tandem PPO 4500/70 OffEx INF (with Infertility Rider) |
07/01/2019 | SBC | |
|
Bronze Tandem PPO 6500/50% OffEx |
01/01/2019 | Summary | SBC |
|
Bronze Tandem PPO 6500/50% OffEx INF (with Infertility Rider) |
01/01/2019 | SBC | |
|
2019 Medical HMO MIrror Package |
|||
|
Blue Shield Trio Platinum 90 HMO 0/15 + Child Dental |
01/01/2019 | Summary | SBC |
|
Blue Shield Trio Platinum 90 HMO 0/15 + Child Dental INF (with Infertility Rider) |
01/01/2019 | SBC | |
|
Blue Shield Trio Gold 80 HMO 0/30 + Child Dental |
01/01/2019 | Summary | SBC |
|
Blue Shield Trio Gold 80 HMO 0/30 + Child Dental INF (with Infertility Rider) |
01/01/2019 | SBC | |
|
Blue Shield Trio Silver 70 HMO 2000/45 + Child Dental |
01/01/2019 | Summary | SBC |
|
Blue Shield Trio Silver 70 HMO 2000/45 + Child Dental INF (with Infertility Rider) |
01/01/2019 | SBC | |
|
2019 Medical PPO Mirror Package |
|||
|
Blue Shield Platinum 90 PPO 0/15 + Child Dental |
01/01/2019 | Summary | SBC |
|
Blue Shield Platinum 90 PPO 0/15 + Child Dental INF (with Infertility Rider) |
01/01/2019 | SBC | |
|
Blue Shield Gold 80 PPO 0/30 + Child Dental |
01/01/2019 | Summary | SBC |
|
Blue Shield Gold 80 PPO 0/30 + Child Dental INF (with Infertility Rider) |
01/01/2019 | SBC | |
|
Blue Shield Silver 70 PPO 2000/45 + Child Dental |
01/01/2019 | Summary | SBC |
|
Blue Shield Silver 70 PPO 2000/45 + Child Dental INF (with Infertility Rider) |
01/01/2019 | SBC | |
|
Blue Shield Bronze 60 PPO 6300/75 + Child Dental |
01/01/2019 | Summary | SBC |
|
Blue Shield Bronze 60 PPO 6300/75 + Child Dental INF (with Infertility Rider) |
01/01/2019 | SBC | |
|
2019 Infertility Riders |
|||
|
Infertility Rider for HMO Plans |
01/01/2019 | Summary | |
|
Infertility Rider for PPO Plans |
01/01/2019 | Summary | |
|
2019 Disclosures (pending) |
|||
|
2019 Dental Plans |
|||
|
DHMO Plans |
|||
|
Dental HMO Basic |
01/01/2019 | Summary | |
|
Dental HMO Standard |
01/01/2019 | Summary | |
|
Dental HMO Plus |
01/01/2019 | Summary | |
|
Dental HMO Deluxe |
01/01/2019 | Summary | |
|
Dental HMO Voluntary |
01/01/2019 | Summary | |
|
Dental PPO - Plans Effective April 1, 2019 |
|||
|
Ultimate Dental Plus PPO for Small Business 50/2000/MAC/NR |
04/01/2019 | Summary | |
|
Ultimate Dental PPO for Small Business 50/2000/MAC/NR |
04/01/2019 | Summary | |
|
Ultimate Dental PPO for Small Business 50/2000/No Ortho/U80 |
04/01/2019 | Summary | |
|
Smile Deluxe Plus 2000 50/2000/Ortho/MAC/NR |
04/01/2019 | Summary | |
|
Smile Deluxe Gold 50/1500/Ortho/U85/NR |
04/01/2019 | Summary | |
|
Smile Deluxe 2000 50/2000/No Ortho/MAC/NR |
04/01/2019 | Summary | |
|
Smile Deluxe 50/1500/Ortho/MAC/NR |
04/01/2019 | Summary | |
|
Smile Plus Gold 50/1500/Ortho/U85/NR |
04/01/2019 | Summary | |
|
Smile Plus Gold 50/1500/Ortho/U80 |
04/01/2019 | Summary | |
|
Smile Plus Gold 50/1500/Ortho/U80/ADV |
04/01/2019 | Summary | |
|
Smile Plus Gold 50/1500/No Ortho/U80 |
04/01/2019 | Summary | |
|
Smile Plus 50/1500/Ortho/MAC/NR |
04/01/2019 | Summary | |
|
Smile Plus 50/1500/No Ortho/MAC |
04/01/2019 | Summary | |
|
Smile Plus 50/1500/No Ortho/MAC/WP |
04/01/2019 | Summary | |
|
Smile 50/1500/No Ortho/MAC/NR |
04/01/2019 | Summary | |
|
Smile Value 50/1500/No Ortho/MAC/NR |
04/01/2019 | Summary | |
|
Smile Basic 50/1000/Ortho/U85 |
04/01/2019 | Summary | |
|
Smile Basic 50/1000/No Ortho/MAC |
04/01/2019 | Summary | |
|
Smile Basic 75/1000/No Ortho/MAC/NR |
04/01/2019 | Summary | |
|
Smile Basic Voluntary 50/1500/Ortho/U80 |
04/01/2019 | Summary | |
|
Smile Basic Voluntary 50/1000/No Ortho/U80 |
04/01/2019 | Summary | |
|
Smile Basic Voluntary 50/1000/No Ortho/MAC |
04/01/2019 | Summary | |
|
Smile Basic Voluntary 75/1000/No Ortho/MAC/NR |
04/01/2019 | Summary | |
|
Dental PPO Plans with Rollover Rewards - Available to Renewing Groups Only as of April 1, 2019 |
|||
|
Ultimate Dental Plus PPO for Small Business 50/2000 MAC |
01/01/2019 | Summary | |
|
Ultimate Dental PPO for Small Business 50/2000 MAC |
01/01/2019 | Summary | |
|
Smile Deluxe Plus 2000 50/2000 Ortho/MAC |
01/01/2019 | Summary | |
|
Smile Deluxe Gold 50/1500 Ortho/U85 |
01/01/2019 | Summary | |
|
Smile Deluxe 2000 50/2000/No Ortho/MAC |
01/01/2019 | Summary | |
|
Smile Deluxe 50/1500/Ortho/MAC |
01/01/2019 | Summary | |
|
Smile Plus Gold 50/1500 Ortho/U85 |
01/01/2019 | Summary | |
|
Smile Plus 50/1500 Ortho/MAC |
01/01/2019 | Summary | |
|
Smile 50/1500/No Ortho/MAC |
01/01/2019 | Summary | |
|
Smile Value 50/1500/No Ortho/MAC |
01/01/2019 | Summary | |
|
Smile Basic 75/1000/No Ortho/MAC |
01/01/2019 | Summary | |
|
Smile Basic Voluntary 75/1000/No Ortho/MAC |
01/01/2019 | Summary | |
|
Dental INO Plans with Rollover Rewards - Available to Renewing Groups Only as of January 1, 2019 |
|||
|
Smile INO Dental Plan 50/1500/Endo-Perio 80%/_No Ortho |
01/01/2019 | Summary | |
|
Smile INO Dental Plan 50/1500/Endo-Perio 80%/Ortho |
01/01/2019 | Summary | |
|
Smile INO Dental Plan 50/2500/Endo-Perio 80%/No Ortho |
01/01/2019 | Summary | |
|
Smile INO Dental Plan 50/2500/Endo-Perio 80%/Ortho |
01/01/2019 | Summary | |
|
Smile INO Dental Voluntary Plan 50/1500/Endo-Perio 50%/No Ortho |
01/01/2019 | Summary | |
|
Smile INO Dental Voluntary Plan 50/1500/Endo-Perio 50%/Ortho |
01/01/2019 | Summary | |
|
Smile INO Dental Voluntary Plan 50/2500/Endo-Perio 50%/No Ortho |
01/01/2019 | Summary | |
|
Smile INO Dental Voluntary Plan 50/2500/Endo-Perio 50%/Ortho |
01/01/2019 | Summary | |
|
2019 Vision Plans |
|||
|
Ultimate Vision Plans (12/12/12) |
|||
|
Ultimate Vision 0/0/120 |
01/01/2019 | Summary | |
|
Ultimate Vision 0/0/150 |
01/01/2019 | Summary | |
|
Ultimate Vision 10/25/120 |
01/01/2019 | Summary | |
|
Ultimate Vision 10/25/150 |
01/01/2019 | Summary | |
|
Ultimate Vision Plus 0/0/150/120 |
01/01/2019 | Summary | |
|
Ultimate Vision Plus 10/25/150/120 |
01/01/2019 | Summary | |
|
Ultimate Vision Voluntary 10/25/150 |
01/01/2019 | Summary | |
|
Preferred Vision Plans (12/12/24) |
|||
|
Preferred Vision 0/0/120 |
01/01/2019 | Summary | |
|
Preferred Vision 0/0/150 |
01/01/2019 | Summary | |
|
Preferred Vision 10/25/120 |
01/01/2019 | Summary | |
|
Preferred Vision 10/25/150 |
01/01/2019 | Summary | |
|
Preferred Vision Plus 0/0/150/120 |
01/01/2019 | Summary | |
|
Preferred Vision Plus 10/25/150/120 |
01/01/2019 | Summary | |
|
Preferred Vision Voluntary 10/25/120 |
01/01/2019 | Summary | |
|
Basic Vision Plans (12/24/24) |
|||
|
Basic Vision 0/0/120 |
01/01/2019 | Summary | |
|
Basic Vision 0/0/150 |
01/01/2019 | Summary | |
|
Basic Vision 10/25/120 |
01/01/2019 | Summary | |
|
Basic Vision 10/25/150 |
01/01/2019 | Summary | |
|
Basic Vision Plus 0/0/150/120 |
01/01/2019 | Summary | |
|
Basic Vision Plus 10/25/150/120 |
01/01/2019 | Summary | |
|
Basic Vision Voluntary 10/25/120 |
01/01/2019 | Summary | |
|
2019 Basic Group Term Life and AD&D Flat Benefit Plans |
|||
|
Basic Group Term Life and AD&D - $15,000 |
01/01/2019 | Summary | |
|
Basic Group Term Life and AD&D - $20,000 |
01/01/2019 | Summary | |
|
Basic Group Term Life and AD&D - $25,000 |
01/01/2019 | Summary | |
|
Basic Group Term Life and AD&D - $30,000 |
01/01/2019 | Summary | |
|
Basic Group Term Life and AD&D - $50,000 |
01/01/2019 | Summary | |
|
Basic Group Term Life and AD&D - $75,000 |
01/01/2019 | Summary | |
|
Basic Group Term Life and AD&D - $100,000 |
01/01/2019 | Summary | |
|
Basic Group Term Life and AD&D - $150,000 |
01/01/2019 | Summary | |
|
2018 Medical HMO Off-Exchange Package |
|||
|
Access+ HMO Network |
|||
|
Platinum Access+ HMO 0/20 OffEx |
01/01/2018 | Summary | SBC |
|
Platinum Access+ HMO 0/20 OffEx INF (with Infertility Rider) |
01/01/2018 | SBC | |
|
Platinum Access+ HMO 0/25 OffEx |
01/01/2018 | Summary | SBC |
|
Platinum Access+ HMO 0/25 OffEx INF (with Infertility Rider) |
01/01/2018 | SBC | |
|
Platinum Access+ HMO 0/30 OffEx |
01/01/2018 | Summary | SBC |
|
Platinum Access+ HMO 0/30 OffEx INF (with Infertility Rider) |
01/01/2018 | SBC | |
|
Gold Access+ HMO 500/35 OffEx |
01/01/2018 | Summary | SBC |
|
Gold Access+ HMO 500/35 OffEx INF (with Infertility Rider) |
01/01/2018 | SBC | |
|
Gold Access+ HMO 1700/35 OffEx |
01/01/2018 | Summary | SBC |
|
Gold Access+ HMO 1700/35 OffEx INF (with Infertility Rider) |
01/01/2018 | SBC | |
|
Silver Access+ HMO 1750/55 OffEx |
01/01/2018 | Summary | SBC |
|
Silver Access+ HMO 1750/55 OffEx INF (with Infertility Rider) |
01/01/2018 | SBC | |
|
Local Access+ HMO Network |
|||
|
Platinum Local Access+ HMO 0/20 OffEx |
01/01/2018 | Summary | SBC |
|
Platinum Local Access+ HMO 0/20 OffEx INF (with Infertility Rider) |
01/01/2018 | SBC | |
|
Platinum Local Access+ HMO 0/25 OffEx |
01/01/2018 | Summary | SBC |
|
Platinum Local Access+ HMO 0/25 OffEx INF (with Infertility Rider) |
01/01/2018 | SBC | |
|
Platinum Local Access+ HMO 0/30 OffEx |
01/01/2018 | Summary | SBC |
|
Platinum Local Access+ HMO 0/30 OffEx INF (with Infertility Rider) |
01/01/2018 | SBC | |
|
Gold Local Access+ HMO 500/35 OffEx |
01/01/2018 | Summary | SBC |
|
Gold Local Access+ HMO 500/35 OffEx INF (with Infertility Rider) |
01/01/2018 | SBC | |
|
Gold Local Access+ HMO 1700/35 OffEx |
01/01/2018 | Summary | SBC |
|
Gold Local Access+ HMO 1700/35 OffEx INF (with Infertility Rider) |
01/01/2018 | SBC | |
|
Silver Local Access+ HMO 1750/55 OffEx |
01/01/2018 | Summary | SBC |
|
Silver Local Access+ HMO 1750/55 OffEx INF (with Infertility Rider) |
01/01/2018 | SBC | |
|
Trio HMO Network |
|||
|
Platinum Trio HMO 0/20 OffEx |
01/01/2018 | Summary | SBC |
|
Platinum Trio HMO 0/20 OffEx INF (with Infertility Rider) |
01/01/2018 | SBC | |
|
Platinum Trio HMO 0/25 OffEx |
01/01/2018 | Summary | SBC |
|
Platinum Trio HMO 0/25 OffEx INF (with Infertility Rider) |
01/01/2018 | SBC | |
|
Platinum Trio HMO 0/30 OffEx |
01/01/2018 | Summary | SBC |
|
Platinum Trio HMO 0/30 OffEx INF (with Infertility Rider) |
01/01/2018 | SBC | |
|
Gold Trio HMO 500/35 OffEx |
01/01/2018 | Summary | SBC |
|
Gold Trio HMO 500/35 OffEx INF (with Infertility Rider) |
01/01/2018 | SBC | |
|
Gold Trio HMO 1700/35 OffEx |
01/01/2018 | Summary | SBC |
|
Gold Trio HMO 1700/35 OffEx INF (with Infertility Rider) |
01/01/2018 | SBC | |
|
Silver Trio HMO 1750/55 OffEx |
01/01/2018 | Summary | SBC |
|
Silver Trio HMO 1750/55 OffEx INF (with Infertility Rider) |
01/01/2018 | SBC | |
|
2018 Medical PPO Off-Exchange Package |
|||
|
Full PPO Network |
|||
|
Platinum Full PPO 0/10 OffEx |
01/01/2018 | Summary | SBC |
|
Platinum Full PPO 0/10 OffEx INF (with Infertility Rider) |
01/01/2018 | SBC | |
|
Platinum Full PPO 250/15 OffEx |
01/01/2018 | Summary | SBC |
|
Platinum Full PPO 250/15 OffEx INF (with Infertility Rider) |
01/01/2018 | SBC | |
|
Gold Full PPO 0/20 OffEx |
01/01/2018 | Summary | SBC |
|
Gold Full PPO 0/20 OffEx INF (with Infertility Rider) |
01/01/2018 | SBC | |
|
Gold Full PPO 450/30 OffEx |
01/01/2018 | Summary | SBC |
|
Gold Full PPO 450/30 OffEx INF (with Infertility Rider) |
01/01/2018 | SBC | |
|
Gold Full PPO 750/30 OffEx |
01/01/2018 | Summary | SBC |
|
Gold Full PPO 750/30 OffEx INF (with Infertility Rider) |
01/01/2018 | SBC | |
|
Gold Full PPO 1200/35 OffEx |
01/01/2018 | Summary | SBC |
|
Gold Full PPO 1200/35 OffEx INF (with Infertility Rider) |
01/01/2018 | SBC | |
|
Silver Full PPO 1700/55 OfEx |
01/01/2018 | Summary | SBC |
|
Silver Full PPO 1700/55 OfEx INF (with Infertility Rider) |
01/01/2018 | SBC | |
|
Silver Full PPO 2000/45 OffEx |
01/01/2018 | Summary | SBC |
|
Silver Full PPO 2000/45 OffEx INF (with Infertility Rider) |
01/01/2018 | SBC | |
|
Silver Full PPO Savings 2000/20% OffEx |
01/01/2018 | Summary | SBC |
|
Silver Full PPO Savings 2000/20% OffEx INF (with Infertility Rider) |
01/01/2018 | SBC | |
|
Bronze Full PPO 3750/65 OffEx |
01/01/2018 | Summary | SBC |
|
Bronze Full PPO 3750/65 OffEx INF (with Infertility Rider) |
01/01/2018 | SBC | |
|
Bronze Full PPO 5700/60 OffEx |
01/01/2018 | Summary | SBC |
|
Bronze Full PPO 5700/60 OffEx INF (with Infertility Rider) |
01/01/2018 | SBC | |
|
Bronze Full PPO Savings 4300/40% OffEx |
01/01/2018 | Summary | SBC |
|
Bronze Full PPO Savings 4300/40% OffEx INF (with Infertility Rider) |
01/01/2018 | SBC | |
|
Bronze Full PPO Savings 6550 OffEx |
01/01/2018 | Summary | SBC |
|
Bronze Full PPO Savings 6550 OffEx INF (with Infertility Rider) |
01/01/2018 | SBC | |
|
Tandem PPO Network |
|||
|
Platinum Tandem PPO 0/10 OffEx |
01/01/2018 | Summary | SBC |
|
Platinum Tandem PPO 0/10 OffEx INF (with Infertility Rider) |
01/01/2018 | SBC | |
|
Platinum Tandem PPO 250/15 OffEx |
01/01/2018 | Summary | SBC |
|
Platinum Tandem PPO 250/15 OffEx INF (with Infertility Rider) |
01/01/2018 | SBC | |
|
Gold Tandem PPO 750/30 OffEx |
01/01/2018 | Summary | SBC |
|
Gold Tandem PPO 750/30 OffEx INF (with Infertility Rider) |
01/01/2018 | SBC | |
|
Silver Tandem PPO 1700/55 OffEx |
01/01/2018 | Summary | SBC |
|
Silver Tandem PPO 1700/55 OffEx INF (with Infertility Rider) |
01/01/2018 | SBC | |
|
Silver Tandem PPO 2000/45 OffEx |
01/01/2018 | Summary | SBC |
|
Silver Tandem PPO 2000/45 OffEx INF (with Infertility Rider) |
01/01/2018 | SBC | |
|
Bronze Tandem PPO 3750/65 OffEx |
01/01/2018 | Summary | SBC |
|
Bronze Tandem PPO 3750/65 OffEx INF (with Infertility Rider) |
01/01/2018 | SBC | |
|
2018 Medical HMO Mirror Package |
|||
|
Platinum 90 HMO 0/15 Trio + Child Dental |
01/01/2018 | Summary | SBC |
|
Platinum 90 HMO 0/15 Trio + Child Dental INF (with Infertility Rider) |
01/01/2018 | SBC | |
|
Gold 80 HMO 0/25 Trio + Child Dental |
01/01/2018 | Summary | SBC |
|
Gold 80 HMO 0/25 Trio + Child Dental INF (with Infertility Rider) |
01/01/2018 | SBC | |
|
Silver 70 HMO 2000/45 Trio + Child Dental |
01/01/2018 | Summary | SBC |
|
Silver 70 HMO 2000/45 Trio + Child Dental INF (with Infertility Rider) |
01/01/2018 | SBC | |
|
2018 Medical PPO Mirror Package |
|||
|
Platinum 90 PPO 0/15 + Child Dental |
01/01/2018 | Summary | SBC |
|
Platinum 90 PPO 0/15 + Child Dental INF (with Infertility Rider) |
01/01/2018 | SBC | |
|
Gold 80 PPO 0/25 + Child Dental |
01/01/2018 | Summary | SBC |
|
Gold 80 PPO 0/25 + Child Dental INF (with Infertility Rider) |
01/01/2018 | SBC | |
|
Silver 70 PPO 2000/45 + Child Dental |
01/01/2018 | Summary | SBC |
|
Silver 70 PPO 2000/45 + Child Dental INF (with Infertility Rider) |
01/01/2018 | SBC | |
|
Bronze 60 PPO 6300/75 + Child Dental |
01/01/2018 | Summary | SBC |
|
Bronze 60 PPO 6300/75 + Child Dental INF (with Infertility Rider) |
01/01/2018 | SBC | |
|
2018 Infertility Riders |
|||
|
Infertility Rider for HMO Plans |
01/01/2018 | Summary | |
|
Infertility Rider for PPO and HSA Plans |
01/01/2018 | Summary | |
|
2018 Disclosures |
|||
|
HMO Plans for Small Business Disclosure |
01/01/2018 | Summary | |
|
PPO Plans for Small Business Disclosure |
01/01/2018 | Summary | |
|
PPO Savings (HSA) Plans for Small Business Disclosure |
01/01/2018 | Summary | |
|
2018 Dental Plans |
|||
|
DHMO Plans |
|||
|
Dental HMO Basic |
01/01/2018 | Summary | |
|
Dental HMO Plus |
01/01/2018 | Summary | |
|
Dental HMO Deluxe |
01/01/2018 | Summary | |
|
Dental HMO Voluntary |
01/01/2018 | Summary | |
|
Dental PPO Plans |
|||
|
Ultimate Dental PPO for Small Business 50/2000 MAC |
01/01/2018 | Summary | |
|
Ultimate Dental Plus PPO for Small Business 50/2000 MAC |
01/01/2018 | Summary | |
|
Smile Deluxe 2000 50/2000/No Ortho/MAC |
01/01/2018 | Summary | |
|
Smile Deluxe Plus 2000 50/2000 Ortho/MAC |
01/01/2018 | Summary | |
|
Smile Deluxe 50/1500 Ortho/MAC |
01/01/2018 | Summary | |
|
Smile Deluxe Gold 50/1500 Ortho/U85 |
01/01/2018 | Summary | |
|
Smile 50/1500/No Ortho/MAC |
01/01/2018 | Summary | |
|
Smile Plus 50/1500 Ortho/MAC |
01/01/2018 | Summary | |
|
Smile Value 50/1500/No Ortho/MAC |
01/01/2018 | Summary | |
|
Smile Plus Gold 50/1500 Ortho/U85 |
01/01/2018 | Summary | |
|
Smile Basic 75/1000/No Ortho/MAC |
01/01/2018 | Summary | |
|
Smile Basic Voluntary 75/1000/No Ortho/MAC |
01/01/2018 | Summary | |
|
Dental INO Plans |
|||
|
Smile INO Dental Plan 50/1500/Endo-Perio 80%/No Ortho |
01/01/2018 | Summary | |
|
Smile INO Dental Plan 50/1500/Endo-Perio 80%/Ortho |
01/01/2018 | Summary | |
|
Smile INO Dental Plan 50/2500 Endo-Perio 80%/No Ortho |
01/01/2018 | Summary | |
|
Smile INO Dental Plan 50/2500 Endo-Perio 80%/Ortho |
01/01/2018 | Summary | |
|
Smile INO Dental Voluntary Plan 50/1500 Endo-Perio 50%/No Ortho |
01/01/2018 | Summary | |
|
Smile INO Dental Voluntary Plan 50/1500 Endo-Perio 50%/Ortho |
01/01/2018 | Summary | |
|
Smile INO Dental Voluntary Plan 50/2500 Endo-Perio 50%/No Ortho |
01/01/2018 | Summary | |
|
Smile INO Dental Voluntary Plan 50/2500 Endo-Perio 50%/Ortho |
01/01/2018 | Summary | |
|
2018 Vision Plans |
|||
|
Enhanced Vision Plans (12/24/24) |
|||
|
Enhanced Vision 0/0/120 |
01/01/2018 | Summary | |
|
Enhanced Vision 0/0/150 |
01/01/2018 | Summary | |
|
Enhanced Vision 15/25/120 |
01/01/2018 | Summary | |
|
Enhanced Vision 15/25/150 |
01/01/2018 | Summary | |
|
Enhanced Vision Plus 0/0/150/120 |
01/01/2018 | Summary | |
|
Enhanced Vision Plus 15/25/150/120 |
01/01/2018 | Summary | |
|
Enhanced Vision Voluntary 15/25/120 |
01/01/2018 | Summary | |
|
Preferred Vision Plans (12/12/24) |
|||
|
Preferred Vision 0/0/120 |
01/01/2018 | Summary | |
|
Preferred Vision 0/0/150 |
01/01/2018 | Summary | |
|
Preferred Vision 15/25/120 |
01/01/2018 | Summary | |
|
Preferred Vision 15/25/150 |
01/01/2018 | Summary | |
|
Preferred Vision Plus 0/0/150/120 |
01/01/2018 | Summary | |
|
Preferred Vision Plus 15/25/150/120 |
01/01/2018 | Summary | |
|
Preferred Vision Voluntary 15/25/120 |
01/01/2018 | Summary | |
|
Ultimate Vision Plans (12/12/12) |
|||
|
Ultimate Vision 0/0/120 |
01/01/2018 | Summary | |
|
Ultimate Vision 0/0/150 |
01/01/2018 | Summary | |
|
Ultimate Vision 15/25/120 |
01/01/2018 | Summary | |
|
Ultimate Vision 15/25/150 |
01/01/2018 | Summary | |
|
Ultimate Vision Plus 0/0/150/120 |
01/01/2018 | Summary | |
|
Ultimate Vision Plus 15/25/150/120 |
01/01/2018 | Summary | |
|
Ultimate Vision Voluntary 15/25/150 |
01/01/2018 | Summary | |
|
2018 Basic Group Term Life and AD&D Flat Benefit Plans |
|||
|
Basic Group Term Life and AD&D - $15,000 |
01/01/2018 | Summary | |
|
Basic Group Term Life and AD&D - $20,000 |
01/01/2018 | Summary | |
|
Basic Group Term Life and AD&D - $25,000 |
01/01/2018 | Summary | |
|
Basic Group Term Life and AD&D - $30,000 |
01/01/2018 | Summary | |
|
Basic Group Term Life and AD&D - $50,000 |
01/01/2018 | Summary | |
|
Basic Group Term Life and AD&D - $75,000 |
01/01/2018 | Summary | |
|
Basic Group Term Life and AD&D - $100,000 |
01/01/2018 | Summary | |
|
Basic Group Term Life and AD&D - $150,000 |
01/01/2018 | Summary |
| Form Name | Effective Date | Download Form |
|---|---|---|
|
General Information |
||
|
Blue Shield Sales Guide 1.19 |
01/01/2019 | Download |
|
Blue Shield Sales Guide 4.19 |
04/01/2019 | Download |
|
Blue Shield Sales Guide 7.19 |
07/01/2019 | Download |
|
Blue Shield Sales Guide 10.19 |
10/01/2019 | Download |
|
Blue Shield Underwriting Guidelines |
01/01/2019 | Download |
|
Employer Connection Plus 2018 Tool Enhancements FAQ |
07/01/2018 | Download |
|
How to Access Your Benefits Online |
01/01/2019 | Download |
|
Online and Mobile Tools |
01/01/2019 | Download |
|
Relaxed Participation Guidelines through 12.19 Effective |
01/01/2019 | Download |
|
Specialty Bundle & Save Flyer |
01/01/2019 | Download |
|
Specialty Quick Facts |
01/01/2019 | Download |
|
What's New for Small Group Q1 2019 |
01/01/2019 | Download |
|
What's New for Small Group Q2 2019 |
04/01/2019 | Download |
|
What's New for Small Group Q3 2019 |
07/01/2019 | Download |
|
What's New for Small Group Q4 2019 |
10/01/2019 | Download |
|
Why Blue Shield of California |
01/01/2019 | Download |
|
Why Blue Shield of California Employer Brochure |
01/01/2019 | Download |
|
Medical |
||
|
Access to Care Flyer |
01/01/2019 | Download |
|
Away from Home Care for HMO Members |
01/01/2019 | Download |
|
Blue Card Program for Care Outside California for PPO Members |
01/01/2019 | Download |
|
Blue Shield HMO Network Guide |
01/01/2019 | Download |
|
Diabetes Prevention Program |
01/01/2019 | Download |
|
Easy Steps to Print or Order your ID Card |
01/01/2019 | Download |
|
Epic Hearing Discounts |
01/01/2019 | Download |
|
Fitness Your Way Flyer |
01/01/2019 | Download |
|
Heal Physician Flyer for PPO Members |
01/01/2019 | Download |
|
MailOrder Rx Flyer |
01/01/2019 | Download |
|
Member Discount Programs |
01/01/2019 | Download |
|
NurseHelp Employee Flyer |
01/01/2019 | Download |
|
NurseHelp Employer Brochure |
01/01/2019 | Download |
|
Pediatric Dental & Vision Infographic |
01/01/2019 | Download |
|
Preventive Health Guidelines |
01/01/2019 | Download |
|
Provider Search Instructions |
01/01/2019 | Download |
|
Shield Concierge for Trio Members |
01/01/2019 | Download |
|
Tandem PPO Member Flyer |
01/01/2019 | Download |
|
Teladoc Flyer |
01/01/2019 | Download |
|
Tiered Pharmacy Network Directory |
01/01/2019 | Download |
|
Tiered Pharmacy Network Flyer |
01/01/2019 | Download |
|
Total Health and Wellness - Programs & Services for Blue Shield Members |
01/01/2019 | Download |
|
Treatment Cost Estimator PPO Member Flyer |
01/01/2019 | Download |
|
Treatment Cost Estimator Step by Step for PPO Members |
01/01/2019 | Download |
|
Trio HMO Brochure |
01/01/2019 | Download |
|
Trio Network Guide |
01/01/2019 | Download |
|
Trio Prenatal Care Flyer |
01/01/2019 | Download |
|
Trio Qualification Tool |
01/01/2019 | Download |
|
Urgent Care Flyer |
01/01/2019 | Download |
|
Vaccines at Retail Pharmacies |
01/01/2019 | Download |
|
Wellness Discounts for Blue Shield Members |
01/01/2019 | Download |
|
Wellvolution flyer |
01/01/2019 | Download |
|
Women's Preventive Health |
01/01/2019 | Download |
|
Dental |
||
|
Broker Dental Brochure 1.19 |
01/01/2019 | Download |
|
Broker Dental Brochure 4.19 |
04/01/2019 | Download |
|
Broker Specialty Bundling Flyer |
01/01/2019 | Download |
|
Caries Risk Management & Assessment |
01/01/2019 | Download |
|
Dental Implant FAQ |
01/01/2019 | Download |
|
Dental Network Map |
01/01/2019 | Download |
|
Dental Smile Rollover Rewards Program (not available on new DPPO plans as of 4.1.19) |
01/01/2019 | Download |
|
Dentist Nomination Form |
01/01/2019 | Download |
|
Guide to Managing your Dental Plan Online |
01/01/2019 | Download |
|
Member Guide to Orthodontic Coverage |
01/01/2019 | Download |
|
Vision |
||
|
Broker Vision Brochure |
01/01/2019 | Download |
|
Managing Your Vision Plan Online |
01/01/2019 | Download |
|
Vision Network at a Glance |
01/01/2019 | Download |
|
Vision Plan Information Card for CA Members |
01/01/2019 | Download |
|
Vision Plan Information Card for Out-of-State Members |
01/01/2019 | Download |
|
Life |
||
|
Broker Life Brochure |
01/01/2019 | Download |
|
Basic Life/AD&D Quick Match Program Guidelines |
01/01/2019 | Download |
|
LifeReferrals 24/7 - Beneficiary Assistance Program |
01/01/2019 | Download |
|
Travel Assistance Program Brochure |
01/01/2019 | Download |
