Blue Shield of California

Form Name	Effective Date	Download Form
New Group Submission
New Group Submission Checklist 4.21	04/01/2021	Download
Express Enrollment Guidelines	01/01/2020	Download
Employer Application 1.21 Effective Dates	01/01/2021	Download
Employer Application 4.21 Effective Dates	04/01/2021	Download
Small Business Owner Eligibility Statement	02/01/2020	Download
Small Group Check by Fax Form	01/01/2020	Download
Start-up Spin-off Companies Small Business Eligibility Statement	02/01/2020	Download
In Force Group Forms
Employer Group Change Request Form 1.21 Effective Dates	01/01/2021	Download
Employer Group Change Request Form 4.21 Effective Dates	04/01/2021	Download
Multiple Subscriber Change Spreadsheet	01/01/2020	Download
Employee Cancellation Notification	10/01/2020	Download
Employer Notification of Qualifying Events under Cal-COBRA	10/01/2020	Download
CMS Reporting Form	01/01/2020	Download
Administration
2021 Group Administrator's Guide	01/01/2021	Download
Employer Connection Plus FAQ & QuickStart Guide	01/01/2020	Download
Employer Connection Plus Online Bill Payment FAQ	01/01/2020	Download
Employer Connection Plus Open Enrollment Guide	01/01/2020	Download

Form Name	Effective Date	Download Form
Enrollment and Change Forms
Small Group Employee Enrollment Form 1.21 Effective Dates	01/01/2021	Download
Refusal of Coverage Form 1.21	01/01/2021	Download
Small Group Employee Enrollment Form 4.21 Effective Dates	04/01/2021	Download
Refusal of Coverage Form 4.21	04/01/2021	Download
Continuity of Care Program Brochure	01/01/2020	Download
Continuity of Care Services Request Form	01/01/2020	Download
Declaration of Disability for Over-Age Dependent Child	01/01/2020	Download
Prior Carrier Deductible Instructions and Form	01/01/2020	Download
Subscriber Change Request Form 1.21 Effective Dates	01/01/2021	Download
Subscriber Change Request Form 4.21 Effective Dates	04/01/2021	Download
COBRA and Cal-COBRA Forms
Continuation of Coverage Application (COBRA and Cal-COBRA)	10/01/2020	Download
Continuing Group Coverage After Federal COBRA Cal-COBRA Election Form	01/01/2020	Download
Cal-COBRA Take-Over Form	01/01/2020	Download
Cal-COBRA Election Form	01/01/2020	Download
Cal-COBRA Dental Election Form	01/01/2020	Download
Claim Forms
Authorization for the Use or Disclosure of Health Information	01/01/2020	Download
Medical Claim Form	01/01/2020	Download
Medical Claim Form - Blue Shield Life	01/01/2020	Download
Pharmacy Reimbursement Form	01/01/2020	Download
Global Care International Claim Form	01/01/2020	Download
Dental Claim Form	01/01/2020	Download
Vision Claim Form	01/01/2020	Download
Proof of Death Form - Group Life	01/01/2020	Download
Dismemberment Claim Form - Group Life	01/01/2020	Download
Accelerated Death Benefit Claim Form - Group Life	01/01/2020	Download
Waiver of Premium Claim Form - Group Life	01/01/2020	Download

Form Name	Effective Date	Download Form
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
Tandom 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
Basic Vision 0/0/150	01/01/2021	Summary
Basic Vision 10/25/120	01/01/2021	Summary
Basic Vision 10/25/150	01/01/2021	Summary
Basic Vision Plus 0/0/150/120	01/01/2021	Summary
Basic Vision Plus 10/25/150/120	01/01/2021	Summary
Basic Vision Voluntary 10/25/120	01/01/2021	Summary
2021 Basic Group Term Life and AD&D Flat Benefit Plans
Basic Group Term Life and AD&D - $15,000	01/01/2021	Summary
Basic Group Term Life and AD&D - $20,000	01/01/2021	Summary
Basic Group Term Life and AD&D - $25,000	01/01/2021	Summary
Basic Group Term Life and AD&D - $30,000	01/01/2021	Summary
Basic Group Term Life and AD&D - $35,000	01/01/2021	Summary
Basic Group Term Life and AD&D - $40,000	01/01/2021	Summary
Basic Group Term Life and AD&D - $45,000	01/01/2021	Summary
Basic Group Term Life and AD&D - $50,000	01/01/2021	Summary
Basic Group Term Life and AD&D - $55,000	01/01/2021	Summary
Basic Group Term Life and AD&D - $60,000	01/01/2021	Summary
Basic Group Term Life and AD&D - $65,000	01/01/2021	Summary
Basic Group Term Life and AD&D - $70,000	01/01/2021	Summary
Basic Group Term Life and AD&D - $75,000	01/01/2021	Summary
Basic Group Term Life and AD&D - $80,000	01/01/2021	Summary
Basic Group Term Life and AD&D - $85,000	01/01/2021	Summary
Basic Group Term Life and AD&D - $90,000	01/01/2021	Summary
Basic Group Term Life and AD&D - $95,000	01/01/2021	Summary
Basic Group Term Life and AD&D - $100,000	01/01/2021	Summary
Basic Group Term Life and AD&D - $105,000	01/01/2021	Summary
Basic Group Term Life and AD&D - $110,000	01/01/2021	Summary
Basic Group Term Life and AD&D - $115,000	01/01/2021	Summary
Basic Group Term Life and AD&D - $120,000	01/01/2021	Summary
Basic Group Term Life and AD&D - $125,000	01/01/2021	Summary
Basic Group Term Life and AD&D - $130,000	01/01/2021	Summary
Basic Group Term Life and AD&D - $135,000	01/01/2021	Summary
Basic Group Term Life and AD&D - $140,000	01/01/2021	Summary
Basic Group Term Life and AD&D - $145,000	01/01/2021	Summary
Basic Group Term Life and AD&D - $150,000	01/01/2021	Summary
Basic Group Term Life and AD&D - $175,000	01/01/2021	Summary
Basic Group Term Life and AD&D - $200,000	01/01/2021	Summary
2021 Basic Group Term Life and AD&D X Salary Plans
Basic Group Term Life and AD&D - 1X to $30,000	01/01/2021	Summary
Basic Group Term Life and AD&D - 1X to $50,000	01/01/2021	Summary
Basic Group Term Life and AD&D - 1X to $75,000	01/01/2021	Summary
Basic Group Term Life and AD&D - 1X to $100,000	01/01/2021	Summary
Basic Group Term Life and AD&D - 1X to $125,000	01/01/2021	Summary
Basic Group Term Life and AD&D - 1X to $150,000	01/01/2021	Summary
Basic Group Term Life and AD&D - 1X to $175,000	01/01/2021	Summary
Basic Group Term Life and AD&D - 1X to $200,000	01/01/2021	Summary
Basic Group Term Life and AD&D - 1X to $250,000	01/01/2021	Summary
Basic Group Term Life and AD&D - 1X to $300,000	01/01/2021	Summary
Basic Group Term Life and AD&D - 2X to $30,000	01/01/2021	Summary
Basic Group Term Life and AD&D - 2X to $50,000	01/01/2021	Summary
Basic Group Term Life and AD&D - 2X to $75,000	01/01/2021	Summary
Basic Group Term Life and AD&D - 2X to $100,000	01/01/2021	Summary
Basic Group Term Life and AD&D - 2X to $125,000	01/01/2021	Summary
Basic Group Term Life and AD&D - 2X to $150,000	01/01/2021	Summary
Basic Group Term Life and AD&D - 2X to $175,000	01/01/2021	Summary
Basic Group Term Life and AD&D - 2X to $200,000	01/01/2021	Summary
Basic Group Term Life and AD&D - 2X to $250,000	01/01/2021	Summary
Basic Group Term Life and AD&D - 2X to $300,000	01/01/2021	Summary
Basic Group Term Life and AD&D - 2X to $350,000	01/01/2021	Summary
Basic Group Term Life and AD&D - 2X to $400,000	01/01/2021	Summary
Basic Group Term Life and AD&D - 2X to $450,000	01/01/2021	Summary
Basic Group Term Life and AD&D - 2X to $500,000	01/01/2021	Summary
Basic Group Term Life and AD&D - 2X to $550,000	01/01/2021	Summary
Basic Group Term Life and AD&D - 2X to $600,000	01/01/2021	Summary
2020 Medical HMO Off-Exchange Package
Access+ HMO Network
Platinum Access+ HMO 0/20 OffEx	01/01/2020	Summary	SBC
Platinum Access+ HMO 0/25 OffEx	01/01/2020	Summary	SBC
Platinum Access+ HMO 0/30 OffEx	01/01/2020	Summary	SBC
Gold Access+ HMO 0/30 OffEx	01/01/2020	Summary	SBC
Gold Access+ HMO 500/35 OffEx	01/01/2020	Summary	SBC
Gold Access+ HMO 1000/35 OffEx	01/01/2020	Summary	SBC
Gold Access+ HMO 1500/35 OffEx	01/01/2020	Summary	SBC
Silver Access+ HMO 2350/65 OffEx	01/01/2020	Summary	SBC
Local Access+ HMO Network
Platinum Local Access+ HMO 0/20 OffEx	01/01/2020	Summary	SBC
Platinum Local Access+ HMO 0/25 OffEx	01/01/2020	Summary	SBC
Platinum Local Access+ HMO 0/30 OffEx	01/01/2020	Summary	SBC
Gold Local Access+ HMO 0/30 OffEx	01/01/2020	Summary	SBC
Gold Local Access+ HMO 500/35 OffEx	01/01/2020	Summary	SBC
Gold Local Access+ HMO 1000/35 OffEx	01/01/2020	Summary	SBC
Gold Local Access+ HMO 1500/35 OffEx	01/01/2020	Summary	SBC
Silver Local Access+ HMO 2350/65 OffEx	01/01/2020	Summary	SBC
Trio HMO Network
Platinum Trio HMO 0/20 OffEx	01/01/2020	Summary	SBC
Platinum Trio HMO 0/25 OffEx	01/01/2020	Summary	SBC
Platinum Trio HMO 0/30 OffEx	01/01/2020	Summary	SBC
Gold Trio HMO 0/30 OffEx	01/01/2020	Summary	SBC
Gold Trio HMO 500/35 OffEx	01/01/2020	Summary	SBC
Gold Trio HMO 1000/35 OffEx	01/01/2020	Summary	SBC
Gold Trio HMO 1500/35 OffEx	01/01/2020	Summary	SBC
Silver Trio HMO 2350/65 OffEx	01/01/2020	Summary	SBC
2020 Medical PPO Off-Exchange Package
Full PPO Network
Platinum Full PPO 0/0 OffEx	01/01/2020	Summary	SBC
Platinum Full PPO 0/10 OffEx	01/01/2020	Summary	SBC
Platinum Full PPO 250/15 OffEx	01/01/2020	Summary	SBC
Gold Full PPO 0/20 OffEx	01/01/2020	Summary	SBC
Gold Full PPO 500/30 OffEx	01/01/2020	Summary	SBC
Gold Full PPO 750/30 OffEx	01/01/2020	Summary	SBC
Gold Full PPO 1200/35 OffEx	01/01/2020	Summary	SBC
Silver Full PPO 1800/55 OffEx	01/01/2020	Summary	SBC
Silver Full PPO 2300/45 OffEx	01/01/2020	Summary	SBC
Silver Full PPO Savings 2000/25% OffEx	01/01/2020	Summary	SBC
Silver Full PPO Savings 2500/35% OffEx	01/01/2020	Summary	SBC
Bronze Full PPO 5000/70 OffEx	01/01/2020	Summary	SBC
Bronze Full PPO 6500/50 OffEx	01/01/2020	Summary	SBC
Bronze Full PPO 6850/65 OffEx	01/01/2020	Summary	SBC
Bronze Full PPO Savings 5300/40% OffEx	01/01/2020	Summary	SBC
Bronze Full PPO Savings 6900 OffEx	01/01/2020	Summary	SBC
Tandom PPO Network
Platinum Tandem PPO 0/0 OffEx	01/01/2020	Summary	SBC
Platinum Tandem PPO 0/10 OffEx	01/01/2020	Summary	SBC
Platinum Tandem PPO 250/15 OffEx	01/01/2020	Summary	SBC
Gold Tandem PPO 0/20 OffEx	01/01/2020	Summary	SBC
Gold Tandem PPO 500/30 OffEx	01/01/2020	Summary	SBC
Gold Tandem PPO 750/30 OffEx	01/01/2020	Summary	SBC
Gold Tandem PPO 1200/35 OffEx	01/01/2020	Summary	SBC
Silver Tandem PPO 1800/55 OffEx	01/01/2020	Summary	SBC
Silver Tandem PPO 2300/45 OffEx	01/01/2020	Summary	SBC
Silver Tandem PPO Savings 2000/25% OffEx	01/01/2020	Summary	SBC
Silver Tandem PPO Savings 2500/35% OffEx	01/01/2020	Summary	SBC
Bronze Tandem PPO 5000/70 OffEx	01/01/2020	Summary	SBC
Bronze Tandem PPO 6500/50 OffEx	01/01/2020	Summary	SBC
Bronze Tandem PPO 6850/65 OffEx	01/01/2020	Summary	SBC
Bronze Tandem PPO Savings 5300/40% OffEx	01/01/2020	Summary	SBC
Bronze Tandem PPO Savings 6900 OffEx	01/01/2020	Summary	SBC
2020 Medical HMO Mirror Package
Blue Shield Trio Platinum 90 HMO 0/15 + Child Dental	01/01/2020	Summary	SBC
Blue Shield Trio Platinum 90 HMO 0/15 + Child Dental INF (with Infertility Rider)	01/01/2020		SBC
Blue Shield Trio Gold 80 HMO 250/25 + Child Dental	01/01/2020	Summary	SBC
Blue Shield Trio Gold 80 HMO 250/25 + Child Dental INF (with Infertility Rider)	01/01/2020		SBC
Blue Shield Trio Silver 70 HMO 2250/50 + Child Dental	01/01/2020	Summary	SBC
Blue Shield Trio Silver 70 HMO 2250/50 + Child Dental INF (with Infertility Rider)	01/01/2020		SBC
2020 Medical PPO Mirror Package
Blue Shield Platinum 90 PPO 0/15 + Child Dental	01/01/2020	Summary	SBC
Blue Shield Platinum 90 PPO 0/15 + Child Dental INF (with Infertility Rider)	01/01/2020		SBC
Blue Shield Gold 80 PPO 250/25 + Child Dental	01/01/2020	Summary	SBC
Blue Shield Gold 80 PPO 250/25 + Child Dental INF (with Infertility Rider)	01/01/2020		SBC
Blue Shield Silver 70 PPO 2250/50 + Child Dental	01/01/2020	Summary	SBC
Blue Shield Silver 70 PPO 2250/50 + Child Dental INF (with Infertility Rider)	01/01/2020		SBC
Blue Shield Bronze 60 PPO 6300/65 + Child Dental	01/01/2020	Summary	SBC
Blue Shield Bronze 60 PPO 6300/65 + Child Dental INF (with Infertility Rider)	01/01/2020		SBC
2020 Infertility Riders
Infertility Rider for HMO Plans	01/01/2020	Summary
Infertility Rider for PPO Plans	01/01/2020	Summary
2020 Dental Plans
DHMO Plans
Dental HMO Basic	01/01/2020	Summary
Dental HMO Standard	01/01/2020	Summary
Dental HMO Plus	01/01/2020	Summary
Dental HMO Deluxe	01/01/2020	Summary
Dental HMO Voluntary	01/01/2020	Summary
Dental PPO
DPPO Plans with ADV
Smile Plus Gold 50/1500/Ortho/U80/ADV	01/01/2020	Summary
Smile Plus Gold 50/1500/Ortho/U90/ADV [new for 2020]	01/01/2020	Summary
Smile Plus Gold 50/1500/No Ortho/U90/ADV [new for 2020]	01/01/2020	Summary
Smile Plus Gold 50/2500/Ortho/U90/ADV [new for 2020]	01/01/2020	Summary
Smile Plus Gold 50/2500/No Ortho/U90/ADV [new for 2020]	01/01/2020	Summary
DPPO Plans without ADV
Ultimate Dental Plus PPO for Small Business 50/2000/MAC/NR	01/01/2020	Summary
Ultimate Dental PPO for Small Business 50/2000/MAC/NR	01/01/2020	Summary
Ultimate Dental PPO for Small Business 50/2000/Lifetime Ortho/U90 [new for 2020]	01/01/2020	Summary
Ultimate Dental PPO for Small Business 50/2000/No Ortho/U80	01/01/2020	Summary
Ultimate Dental PPO for Small Business 50/2000/No Ortho/U90 [new for 2020]	01/01/2020	Summary
Smile Deluxe Plus 2000 50/2000/Ortho/MAC/NR	01/01/2020	Summary
Smile Deluxe Gold 50/1500/Ortho/U85/NR	01/01/2020	Summary
Smile Deluxe 2000 50/2000/No Ortho/MAC/NR	01/01/2020	Summary
Smile Deluxe 50/1500/Ortho/MAC/NR	01/01/2020	Summary
Smile Plus Gold 50/1500/Ortho/U85/NR	01/01/2020	Summary
Smile Plus Gold 50/1500/Ortho/U80	01/01/2020	Summary
Smile Plus Gold 50/1500/No Ortho/U80	01/01/2020	Summary
Smile Plus 50/1500/Ortho/MAC/NR	01/01/2020	Summary
Smile Plus 50/1500/No Ortho/MAC	01/01/2020	Summary
Smile Plus 50/1500/No Ortho/MAC/WP	01/01/2020	Summary
Smile 50/1500/No Ortho/MAC/NR	01/01/2020	Summary
Smile Value 50/1500/No Ortho/MAC/NR	01/01/2020	Summary
Smile Basic 50/1000/Ortho/U85	01/01/2020	Summary
Smile Basic 50/1000/No Ortho/MAC	01/01/2020	Summary
Smile Basic 75/1000/No Ortho/MAC/NR	01/01/2020	Summary
Smile Basic Voluntary 50/1500/Ortho/U80	01/01/2020	Summary
Smile Basic Voluntary 50/1000/No Ortho/U80	01/01/2020	Summary
Smile Basic Voluntary 50/1000/No Ortho/MAC	01/01/2020	Summary
Smile Basic Voluntary 75/1000/No Ortho/MAC/NR	01/01/2020	Summary
Closed Dental PPO Plans with Rollover Rewards - Available to Renewing Groups Only
Ultimate Dental Plus PPO for Small Business 50/2000 MAC	01/01/2020	Summary
Ultimate Dental PPO for Small Business 50/2000 MAC	01/01/2020	Summary
Smile Deluxe Plus 2000 50/2000/Ortho/MAC	01/01/2020	Summary
Smile Deluxe Gold 50/1500/Ortho/U85	01/01/2020	Summary
Smile Deluxe 2000 50/2000/No Ortho/MAC	01/01/2020	Summary
Smile Deluxe 50/1500/Ortho/MAC	01/01/2020	Summary
Smile Plus Gold 50/1500 Ortho/U85	01/01/2020	Summary
Smile Plus 50/1500/Ortho/MAC	01/01/2020	Summary
Smile 50/1500/No Ortho/MAC	01/01/2020	Summary
Smile Value 50/1500/No Ortho/MAC	01/01/2020	Summary
Smile Basic 75/1000/No Ortho/MAC	01/01/2020	Summary
Smile Basic Voluntary 75/1000/No Ortho/MAC	01/01/2020	Summary
Closed Dental INO Plans with Rollover Rewards - Available to Renewing Groups Only
Smile INO Dental Plan 50/1500/Endo-Perio 80%/No Ortho	01/01/2020	Summary
Smile INO Dental Plan 50/1500/Endo-Perio 80%/Ortho	01/01/2020	Summary
Smile INO Dental Plan 50/2500/Endo-Perio 80%/No Ortho	01/01/2020	Summary
Smile INO Dental Plan 50/2500/Endo-Perio 80%/Ortho	01/01/2020	Summary
Smile INO Dental Voluntary Plan 50/1500/Endo-Perio 50%/No Ortho	01/01/2020	Summary
Smile INO Dental Voluntary Plan 50/1500/Endo-Perio 50%/Ortho	01/01/2020	Summary
Smile INO Dental Voluntary Plan 50/2500/Endo-Perio 50%/No Ortho	01/01/2020	Summary
Smile INO Dental Voluntary Plan 50/2500/Endo-Perio 50%/Ortho	01/01/2020	Summary
2020 Vision Plans
Ultimate Vision Plans (12/12/12)
Ultimate Vision 0/0/120	01/01/2020	Summary
Ultimate Vision 0/0/150	01/01/2020	Summary
Ultimate Vision 10/25/120	01/01/2020	Summary
Ultimate Vision 10/25/150	01/01/2020	Summary
Ultimate Vision Plus 0/0/150/120	01/01/2020	Summary
Ultimate Vision Plus 10/25/150/120	01/01/2020	Summary
Ultimate Vision Voluntary 10/25/150	01/01/2020	Summary
Preferred Vision Plans (12/12/24)
Preferred Vision 0/0/120	01/01/2020	Summary
Preferred Vision 0/0/150	01/01/2020	Summary
Preferred Vision 10/25/120	01/01/2020	Summary
Preferred Vision 10/25/150	01/01/2020	Summary
Preferred Vision Plus 0/0/150/120	01/01/2020	Summary
Preferred Vision Plus 10/25/150/120	01/01/2020	Summary
Preferred Vision Voluntary 10/25/120	01/01/2020	Summary
Basic Vision Plans (12/24/24)
Basic Vision 0/0/120	01/01/2020	Summary
Basic Vision 0/0/150	01/01/2020	Summary
Basic Vision 10/25/120	01/01/2020	Summary
Basic Vision 10/25/150	01/01/2020	Summary
Basic Vision Plus 0/0/150/120	01/01/2020	Summary
Basic Vision Plus 10/25/150/120	01/01/2020	Summary
Basic Vision Voluntary 10/25/120	01/01/2020	Summary
2020 Basic Group Term Life and AD&D Flat Benefit Plans
Basic Group Term Life and AD&D - $15,000	01/01/2020	Summary
Basic Group Term Life and AD&D - $20,000	01/01/2020	Summary
Basic Group Term Life and AD&D - $25,000	01/01/2020	Summary
Basic Group Term Life and AD&D - $30,000	01/01/2020	Summary
Basic Group Term Life and AD&D - $35,000	01/01/2020	Summary
Basic Group Term Life and AD&D - $40,000	01/01/2020	Summary
Basic Group Term Life and AD&D - $45,000	01/01/2020	Summary
Basic Group Term Life and AD&D - $50,000	01/01/2020	Summary
Basic Group Term Life and AD&D - $55,000	01/01/2020	Summary
Basic Group Term Life and AD&D - $60,000	01/01/2020	Summary
Basic Group Term Life and AD&D - $65,000	01/01/2020	Summary
Basic Group Term Life and AD&D - $70,000	01/01/2020	Summary
Basic Group Term Life and AD&D - $75,000	01/01/2020	Summary
Basic Group Term Life and AD&D - $80,000	01/01/2020	Summary
Basic Group Term Life and AD&D - $85,000	01/01/2020	Summary
Basic Group Term Life and AD&D - $90,000	01/01/2020	Summary
Basic Group Term Life and AD&D - $95,000	01/01/2020	Summary
Basic Group Term Life and AD&D - $100,000	01/01/2020	Summary
Basic Group Term Life and AD&D - $105,000	01/01/2020	Summary
Basic Group Term Life and AD&D - $110,000	01/01/2020	Summary
Basic Group Term Life and AD&D - $115,000	01/01/2020	Summary
Basic Group Term Life and AD&D - $120,000	01/01/2020	Summary
Basic Group Term Life and AD&D - $125,000	01/01/2020	Summary
Basic Group Term Life and AD&D - $130,000	01/01/2020	Summary
Basic Group Term Life and AD&D - $135,000	01/01/2020	Summary
Basic Group Term Life and AD&D - $140,000	01/01/2020	Summary
Basic Group Term Life and AD&D - $145,000	01/01/2020	Summary
Basic Group Term Life and AD&D - $150,000	01/01/2020	Summary
Basic Group Term Life and AD&D - $175,000	01/01/2020	Summary
Basic Group Term Life and AD&D - $200,000	01/01/2020	Summary
2020 Basic Group Term Life and AD&D X Salary Plans
Basic Group Term Life and AD&D - 1X to $50,000	01/01/2020	Summary
Basic Group Term Life and AD&D - 1X to $75,000	01/01/2020	Summary
Basic Group Term Life and AD&D - 1X to $100,000	01/01/2020	Summary
Basic Group Term Life and AD&D - 1X to $125,000	01/01/2020	Summary
Basic Group Term Life and AD&D - 1X to $150,000	01/01/2020	Summary
Basic Group Term Life and AD&D - 1X to $175,000	01/01/2020	Summary
Basic Group Term Life and AD&D - 1X to $200,000	01/01/2020	Summary
Basic Group Term Life and AD&D - 1X to $250,000	01/01/2020	Summary
Basic Group Term Life and AD&D - 1X to $300,000	01/01/2020	Summary
Basic Group Term Life and AD&D - 2X to $50,000	01/01/2020	Summary
Basic Group Term Life and AD&D - 2X to $75,000	01/01/2020	Summary
Basic Group Term Life and AD&D - 2X to $100,000	01/01/2020	Summary
Basic Group Term Life and AD&D - 2X to $125,000	01/01/2020	Summary
Basic Group Term Life and AD&D - 2X to $150,000	01/01/2020	Summary
Basic Group Term Life and AD&D - 2X to $175,000	01/01/2020	Summary
Basic Group Term Life and AD&D - 2X to $200,000	01/01/2020	Summary
Basic Group Term Life and AD&D - 2X to $250,000	01/01/2020	Summary
Basic Group Term Life and AD&D - 2X to $300,000	01/01/2020	Summary

Form Name	Effective Date	Download Form
General Information
Sales Guide 4.21	04/01/2021	Download
Sales Guide 1.21	01/01/2021	Download
Underwriting Guidelines 4.21	04/01/2021	Download
Underwriting Guidelines 1.21	01/01/2021	Download
How to Print or Order your ID Card	06/01/2020	Download
Online and Mobile Tools	06/01/2020	Download
Relaxed Participation Guidelines through 12.21 Effective Date	12/01/2020	Download
Specialty Bundle & Save Flyer	01/01/2020	Download
Specialty Quick Facts	01/01/2020	Download
Why Blue Shield of California	01/01/2020	Download
Why Blue Shield of California Employer Brochure	01/01/2020	Download
Medical
Access to Care Flyer	01/01/2020	Download
Away from Home Care for HMO Members Flyer	01/01/2020	Download
Blue Card Program for Care Outside California for PPO Members	01/01/2020	Download
Epic Hearing Discounts	01/01/2020	Download
Fitness Your Way Flyer	01/01/2020	Download
Heal Physician Flyer for PPO Members	01/01/2020	Download
HMO Network Guide	05/01/2020	Download
How To Find a Blue Shield PPO Provider Outside of California	01/01/2020	Download
MailOrder Rx Flyer	01/01/2020	Download
NurseHelp Employee Flyer	01/01/2020	Download
Online Provider Search Instructions	01/01/2020	Download
Pediatric Dental & Vision Infographic	01/01/2020	Download
Prescription Drug Formulary	01/01/2020	Download
Preventive Health Guidelines	01/01/2020	Download
Shield Concierge for Trio Members	01/01/2020	Download
Tandem PPO Member Flyer	01/01/2020	Download
Teladoc Flyer	01/01/2020	Download
Tiered Pharmacy Network Directory	01/01/2020	Download
Tiered Pharmacy Network Flyer	01/01/2020	Download
Total Health and Wellness - Programs & Services for Blue Shield Members	01/01/2020	Download
Treatment Cost Estimator PPO Member Flyer	01/01/2020	Download
Trio HMO Brochure	01/01/2020	Download
Trio Prenatal Care Flyer	01/01/2020	Download
Urgent Care Flyer	01/01/2020	Download
Vaccines at Retail Pharmacies	01/01/2020	Download
Wellness Discounts for Blue Shield Members	01/01/2020	Download
Wellvolution flyer	01/01/2020	Download
Women's Preventive Health	01/01/2020	Download
Dental
Broker Dental Brochure	01/01/2020	Download
Caries Risk Management & Assessment	01/01/2020	Download
Dental Implant FAQ	01/01/2020	Download
Dental Network Map	01/01/2020	Download
Dental Smile Rollover Rewards Program (not available on new DPPO plans as of 4.1.19)	01/01/2020	Download
Dentist Nomination Form	01/01/2020	Download
Guide to Managing your Dental Plan Online	01/01/2020	Download
Member Guide to Orthodontic Coverage	01/01/2020	Download
Vision
Broker Vision Brochure	01/01/2020	Download
Managing Your Vision Plan Online	01/01/2020	Download
Vision Network at a Glance	01/01/2020	Download
Vision Plan Information Card for CA Members	01/01/2020	Download
Vision Plan Information Card for Out-of-State Members	01/01/2020	Download
Life
Broker Life Brochure	01/01/2020	Download
Basic Life/AD&D Quick Match Program Guidelines	01/01/2020	Download
LifeReferrals 24/7 - Beneficiary Assistance Program	01/01/2020	Download
Travel Assistance Program Brochure	01/01/2020	Download

Form Name	Effective Date	Download Form
Rate Tables - All Rating Areas [effective 4/1/2021]	04/01/2021	Download
Rate Tables - All Rating Areas [effective 7/1/2021]	07/01/2021	Download

Blue Shield of California

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