| Form Name | Effective Date | Download Form |
|---|---|---|
|
New Group Submission |
||
|
New Group Submission Checklist 1.24 |
01/01/2024 | Download |
|
Employer Application 7.24 Effective Dates |
07/01/2024 | Download |
|
Employer Application 1.24 Effective Dates |
01/01/2024 | Download |
|
Small Business Owner Eligibility Statement |
10/01/2023 | Download |
|
Small Group Initial Payment Form |
06/01/2024 | Download |
|
Start-up Spin-off Companies Small Business Eligibility Statement |
10/01/2023 | Download |
|
In Force Group Forms |
||
|
Employer Group Change Request Form 7.24 Effective Dates |
07/01/2024 | Download |
|
Employer Group Change Request Form 1.24 Effective Dates |
01/01/2024 | Download |
|
Group Information Update Form |
08/01/2022 | Download |
|
Multiple Subscriber Change Spreadsheet |
01/01/2022 | Download |
|
Employee Cancellation Notification |
01/01/2022 | Download |
|
Employer Notification of Qualifying Events under Cal-COBRA |
01/01/2022 | Download |
|
Broker of Record Change Request Form |
04/01/2023 | Download |
|
CMS Reporting Form |
01/01/2022 | Download |
|
Renewal Guide 2023 |
01/01/2023 | Download |
|
Administration |
||
|
2024 Group Administrator's Guide |
01/01/2024 | Download |
|
Employer Enrollment Tool Guide |
04/01/2023 | Download |
| Form Name | Effective Date | Download Form |
|---|---|---|
|
Enrollment and Change Forms |
||
|
Small Group Employee Enrollment Form 7.24 Effective Dates |
07/01/2024 | Download |
|
Small Group Employee Enrollment Form 1.24 Effective Dates |
05/01/2024 | Download |
|
Refusal of Coverage Form 12.23 |
04/01/2024 | Download |
|
Continuity of Care Program Brochure |
01/01/2022 | Download |
|
Continuity of Care Services Request Form |
01/01/2022 | Download |
|
Declaration of Disability for Over-Age Dependent Child |
01/01/2022 | Download |
|
Prior Carrier Deductible Instructions and Form |
08/01/2022 | Download |
|
Subscriber Change Request Form 7.24 Effective Dates |
07/01/2024 | Download |
|
Subscriber Change Request Form 1.24 Effective Dates |
01/01/2024 | 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 | |
|---|---|---|---|
|
2024 Medical HMO Off-Exchange Package |
|||
|
Access+ HMO Network |
|||
|
Platinum Access+ HMO 0/20 OffEx |
01/01/2024 | Summary | SBC |
|
Platinum Access+ HMO 0/20 OffEx INF |
01/01/2024 | SBC | |
|
Platinum Access+ HMO 0/25 OffEx |
01/01/2024 | Summary | SBC |
|
Platinum Access+ HMO 0/25 OffEx INF |
01/01/2024 | SBC | |
|
Platinum Access+ HMO 0/30 OffEx |
01/01/2024 | Summary | SBC |
|
Platinum Access+ HMO 0/30 OffEx INF |
01/01/2024 | SBC | |
|
Gold Access+ HMO 0/35 OffEx |
01/01/2024 | Summary | SBC |
|
Gold Access+ HMO 0/35 OffEx INF |
01/01/2024 | SBC | |
|
Gold Access+ HMO 500/35 OffEx |
01/01/2024 | Summary | SBC |
|
Gold Access+ HMO 500/35 OffEx INF |
01/01/2024 | SBC | |
|
Gold Access+ HMO 1000/35 OffEx |
01/01/2024 | Summary | SBC |
|
Gold Access+ HMO 1000/35 OffEx INF |
01/01/2024 | SBC | |
|
Gold Access+ HMO 1500/35 OffEx |
01/01/2024 | Summary | SBC |
|
Gold Access+ HMO 1500/35 OffEx INF |
01/01/2024 | SBC | |
|
Silver Access+ HMO 2300/70 OffEx |
01/01/2024 | Summary | SBC |
|
Silver Access+ HMO 2300/70 OffEx INF |
01/01/2024 | SBC | |
|
Silver Access+ HMO 2750/70 OffEx |
01/01/2024 | Summary | SBC |
|
Silver Access+ HMO 2750/70 OffEx INF |
01/01/2024 | SBC | |
|
Bronze Access+ HMO 7000/70 OffEx |
01/01/2024 | Summary | SBC |
|
Bronze Access+ HMO 7000/70 OffEx INF |
01/01/2024 | SBC | |
|
Local Access+ HMO Network |
|||
|
Platinum Local Access+ HMO 0/20 OffEx |
01/01/2024 | Summary | SBC |
|
Platinum Local Access+ HMO 0/20 OffEx INF |
01/01/2024 | SBC | |
|
Platinum Local Access+ HMO 0/25 OffEx |
01/01/2024 | Summary | SBC |
|
Platinum Local Access+ HMO 0/25 OffEx INF |
01/01/2024 | SBC | |
|
Platinum Local Access+ HMO 0/30 OffEx |
01/01/2024 | Summary | SBC |
|
Platinum Local Access+ HMO 0/30 OffEx INF |
01/01/2024 | SBC | |
|
Gold Local Access+ HMO 0/35 OffEx |
01/01/2024 | Summary | SBC |
|
Gold Local Access+ HMO 0/35 OffEx INF |
01/01/2024 | SBC | |
|
Gold Local Access+ HMO 500/35 OffEx |
01/01/2024 | Summary | SBC |
|
Gold Local Access+ HMO 500/35 OffEx INF |
01/01/2024 | SBC | |
|
Gold Local Access+ HMO 1000/35 OffEx |
01/01/2024 | Summary | SBC |
|
Gold Local Access+ HMO 1000/35 OffEx INF |
01/01/2024 | SBC | |
|
Gold Local Access+ HMO 1500/35 OffEx |
01/01/2024 | Summary | SBC |
|
Gold Local Access+ HMO 1500/35 OffEx INF |
01/01/2024 | SBC | |
|
Silver Local Access+ HMO 2300/70 OffEx |
01/01/2024 | Summary | SBC |
|
Silver Local Access+ HMO 2300/70 OffEx INF |
01/01/2024 | SBC | |
|
Silver Local Access+ HMO 2750/70 OffEx |
01/01/2024 | Summary | SBC |
|
Silver Local Access+ HMO 2750/70 OffEx INF |
01/01/2024 | SBC | |
|
Bronze Local Access+ HMO 7000/70 OffEx |
01/01/2024 | Summary | SBC |
|
Bronze Local Access+ HMO 7000/70 OffEx INF |
01/01/2024 | SBC | |
|
Trio HMO Network |
|||
|
Platinum Trio HMO 0/20 OffEx |
01/01/2024 | Summary | SBC |
|
Platinum Trio HMO 0/20 OffEx INF |
01/01/2024 | SBC | |
|
Platinum Trio HMO 0/25 OffEx |
01/01/2024 | Summary | SBC |
|
Platinum Trio HMO 0/25 OffEx INF |
01/01/2024 | SBC | |
|
Platinum Trio HMO 0/30 OffEx |
01/01/2024 | Summary | SBC |
|
Platinum Trio HMO 0/30 OffEx INF |
01/01/2024 | SBC | |
|
Gold Trio HMO 0/35 OffEx |
01/01/2024 | Summary | SBC |
|
Gold Trio HMO 0/35 OffEx INF |
01/01/2024 | SBC | |
|
Gold Trio HMO 500/35 OffEx |
01/01/2024 | Summary | SBC |
|
Gold Trio HMO 500/35 OffEx INF |
01/01/2024 | SBC | |
|
Gold Trio HMO 1000/35 OffEx |
01/01/2024 | Summary | SBC |
|
Gold Trio HMO 1000/35 OffEx INF |
01/01/2024 | SBC | |
|
Gold Trio HMO 1500/35 OffEx |
01/01/2024 | Summary | SBC |
|
Gold Trio HMO 1500/35 OffEx INF |
01/01/2024 | SBC | |
|
Silver Trio HMO 2300/70 OffEx |
01/01/2024 | Summary | SBC |
|
Silver Trio HMO 2300/70 OffEx INF |
01/01/2024 | SBC | |
|
Silver Trio HMO 2750/70 OffEx |
01/01/2024 | Summary | SBC |
|
Silver Trio HMO 2750/70 OffEx INF |
01/01/2024 | SBC | |
|
Bronze Trio HMO 7000/70 OffEx |
01/01/2024 | Summary | SBC |
|
Bronze Trio HMO 7000/70 OffEx INF |
01/01/2024 | SBC | |
|
2024 Medical PPO Off-Exchange Package |
|||
|
Full PPO Network |
|||
|
Platinum Full PPO 0/0 OffEx |
01/01/2024 | Summary | SBC |
|
Platinum Full PPO 0/0 OffEx INF |
01/01/2024 | SBC | |
|
Platinum Full PPO 0/10 OffEx |
01/01/2024 | Summary | SBC |
|
Platinum Full PPO 0/10 OffEx INF |
01/01/2024 | SBC | |
|
Platinum Full PPO 250/10 OffEx |
01/01/2024 | Summary | SBC |
|
Platinum Full PPO 250/10 OffEx INF |
01/01/2024 | SBC | |
|
Platinum Full PPO 250/15 OffEx |
01/01/2024 | Summary | SBC |
|
Platinum Full PPO 250/15 OffEx INF |
01/01/2024 | SBC | |
|
Gold Full PPO 0/35 OffEx |
01/01/2024 | Summary | SBC |
|
Gold Full PPO 0/35 OffEx INF |
01/01/2024 | SBC | |
|
Gold Full PPO 500/30 OffEx |
01/01/2024 | Summary | SBC |
|
Gold Full PPO 500/30 OffEx INF |
01/01/2024 | SBC | |
|
Gold Full PPO 750/30 OffEx |
01/01/2024 | Summary | SBC |
|
Gold Full PPO 750/30 OffEx INF |
01/01/2024 | SBC | |
|
Gold Full PPO 1000/35 OffEx |
01/01/2024 | Summary | SBC |
|
Gold Full PPO 1000/35 OffEx INF |
01/01/2024 | SBC | |
|
Gold Full PPO Savings 1750/15% HDHP PrevRx OffEx |
01/01/2024 | Summary | SBC |
|
Gold Full PPO Savings 1750/15% HDHP PrevRx OffEx INF |
01/01/2024 | SBC | |
|
Silver Full PPO 2000/60 OffEx |
01/01/2024 | Summary | SBC |
|
Silver Full PPO 2000/60 OffEx INF |
01/01/2024 | SBC | |
|
Silver Full PPO 2350/65 OffEx |
01/01/2024 | Summary | SBC |
|
Silver Full PPO 2350/65 OffEx INF |
01/01/2024 | SBC | |
|
Silver Full PPO 2550/70 OffEx |
01/01/2024 | Summary | SBC |
|
Silver Full PPO 2550/70 OffEx INF |
01/01/2024 | SBC | |
|
Silver Full PPO Savings 2300/30% OffEx |
01/01/2024 | Summary | SBC |
|
Silver Full PPO Savings 2300/30% OffEx INF |
01/01/2024 | SBC | |
|
Silver Full PPO Savings 2600/35% HDHP PrevRx OffEx |
01/01/2024 | Summary | SBC |
|
Silver Full PPO Savings 2600/35% HDHP PrevRx OffEx INF |
01/01/2024 | SBC | |
|
Bronze Full PPO 5500/65 OffEx |
01/01/2024 | Summary | SBC |
|
Bronze Full PPO 5500/65 OffEx INF |
01/01/2024 | SBC | |
|
Bronze Full PPO 6250/65 OffEx |
01/01/2024 | Summary | SBC |
|
Bronze Full PPO 6250/65 OffEx INF |
01/01/2024 | SBC | |
|
Bronze Full PPO 6500/70 OffEx |
01/01/2024 | Summary | SBC |
|
Bronze Full PPO 6500/70 OffEx INF |
01/01/2024 | SBC | |
|
Bronze Full PPO 6850/55 OffEx |
01/01/2024 | Summary | SBC |
|
Bronze Full PPO 6850/55 OffEx INF |
01/01/2024 | SBC | |
|
Bronze Full PPO 7500/65 OffEx |
01/01/2024 | Summary | SBC |
|
Bronze Full PPO 7500/65 OffEx INF |
01/01/2024 | SBC | |
|
Bronze Full PPO Savings 5700/40% OffEx |
01/01/2024 | Summary | SBC |
|
Bronze Full PPO Savings 5700/40% OffEx INF |
01/01/2024 | SBC | |
|
Bronze Full PPO Savings 7500 OffEx |
01/01/2024 | Summary | SBC |
|
Bronze Full PPO Savings 7500 OffEx INF |
01/01/2024 | SBC | |
|
Tandem PPO Network |
|||
|
Platinum Tandem PPO 0/0 OffEx |
01/01/2024 | Summary | SBC |
|
Platinum Tandem PPO 0/0 OffEx INF |
01/01/2024 | SBC | |
|
Platinum Tandem PPO 0/10 OffEx |
01/01/2024 | Summary | SBC |
|
Platinum Tandem PPO 0/10 OffEx INF |
01/01/2024 | SBC | |
|
Platinum Tandem PPO 250/10 OffEx |
01/01/2024 | Summary | SBC |
|
Platinum Tandem PPO 250/10 OffEx INF |
01/01/2024 | SBC | |
|
Platinum Tandem PPO 250/15 OffEx |
01/01/2024 | Summary | SBC |
|
Platinum Tandem PPO 250/15 OffEx INF |
01/01/2024 | SBC | |
|
Gold Tandem PPO 0/35 OffEx |
01/01/2024 | Summary | SBC |
|
Gold Tandem PPO 0/35 OffEx INF |
01/01/2024 | SBC | |
|
Gold Tandem PPO 500/30 OffEx |
01/01/2024 | Summary | SBC |
|
Gold Tandem PPO 500/30 OffEx INF |
01/01/2024 | SBC | |
|
Gold Tandem PPO 750/30 OffEx |
01/01/2024 | Summary | SBC |
|
Gold Tandem PPO 750/30 OffEx INF |
01/01/2024 | SBC | |
|
Gold Tandem PPO 1000/35 OffEx |
01/01/2024 | Summary | SBC |
|
Gold Tandem PPO 1000/35 OffEx INF |
01/01/2024 | SBC | |
|
Gold Tandem PPO Savings 1750/15% HDHP PrevRx OffEx |
01/01/2024 | Summary | SBC |
|
Gold Tandem PPO Savings 1750/15% HDHP PrevRx OffEx INF |
01/01/2024 | SBC | |
|
Silver Tandem PPO 2000/60 OffEx |
01/01/2024 | Summary | SBC |
|
Silver Tandem PPO 2000/60 OffEx INF |
01/01/2024 | SBC | |
|
Silver Tandem PPO 2350/65 OffEx |
01/01/2024 | Summary | SBC |
|
Silver Tandem PPO 2350/65 OffEx INF |
01/01/2024 | SBC | |
|
Silver Tandem PPO 2550/70 OffEx |
01/01/2024 | Summary | SBC |
|
Silver Tandem PPO 2550/70 OffEx INF |
01/01/2024 | SBC | |
|
Silver Tandem PPO Savings 2300/30% OffEx |
01/01/2024 | Summary | SBC |
|
Silver Tandem PPO Savings 2300/30% OffEx INF |
01/01/2024 | SBC | |
|
Silver Tandem PPO Savings 2600/35% HDHP PrevRx OffEx |
01/01/2024 | Summary | SBC |
|
Silver Tandem PPO Savings 2600/35% HDHP PrevRx OffEx INF |
01/01/2024 | SBC | |
|
Bronze Tandem PPO 5500/65 OffEx |
01/01/2024 | Summary | SBC |
|
Bronze Tandem PPO 5500/65 OffEx INF |
01/01/2024 | SBC | |
|
Bronze Tandem PPO 6250/65 OffEx |
01/01/2024 | Summary | SBC |
|
Bronze Tandem PPO 6250/65 OffEx INF |
01/01/2024 | SBC | |
|
Bronze Tandem PPO 6500/70 OffEx |
01/01/2024 | Summary | SBC |
|
Bronze Tandem PPO 6500/70 OffEx INF |
01/01/2024 | SBC | |
|
Bronze Tandem PPO 6850/55 OffEx |
01/01/2024 | Summary | SBC |
|
Bronze Tandem PPO 6850/55 OffEx INF |
01/01/2024 | SBC | |
|
Bronze Tandem PPO 7500/65 OffEx |
01/01/2024 | Summary | SBC |
|
Bronze Tandem PPO 7500/65 OffEx INF |
01/01/2024 | SBC | |
|
Bronze Tandem PPO Savings 5700/40% OffEx |
01/01/2024 | Summary | SBC |
|
Bronze Tandem PPO Savings 5700/40% OffEx INF |
01/01/2024 | SBC | |
|
Bronze Tandem PPO Savings 7500 OffEx |
01/01/2024 | Summary | SBC |
|
Bronze Tandem PPO Savings 7500 OffEx INF |
01/01/2024 | SBC | |
|
Virtual Blue Tandem PPO Network |
|||
|
Virtual Blue Platinum Tandem PPO 250/20 OffEx |
01/01/2024 | Summary | SBC |
|
Virtual Blue Platinum Tandem PPO 250/20 OffEx INF |
01/01/2024 | SBC | |
|
Virtual Blue Gold Tandem PPO 1500/45 OffEx |
01/01/2024 | Summary | SBC |
|
Virtual Blue Gold Tandem PPO 1500/45 OffEx INF |
01/01/2024 | SBC | |
|
Virtual Blue Silver Tandem PPO 2700/75 OffEx |
01/01/2024 | Summary | SBC |
|
Virtual Blue Silver Tandem PPO 2700/75 OffEx INF |
01/01/2024 | SBC | |
|
Virtual Blue Bronze Tandem PPO 7500/75 OffEx |
01/01/2024 | Summary | SBC |
|
Virtual Blue Bronze Tandem PPO 7500/75 OffEx INF |
01/01/2024 | SBC | |
|
2024 Medical HMO Mirror Package |
|||
|
Access+ HMO Network |
|||
|
Blue Shield Access+ Platinum 90 HMO 0/20 + Child Dental |
01/01/2024 | Summary | SBC |
|
Blue Shield Access+ Platinum 90 HMO 0/20 + Child Dental INF |
01/01/2024 | SBC | |
|
Blue Shield Access+ Gold 80 HMO 250/35 + Child Dental |
01/01/2024 | Summary | SBC |
|
Blue Shield Access+ Gold 80 HMO 250/35 + Child Dental INF |
01/01/2024 | SBC | |
|
Blue Shield Access+ Silver 70 HMO 2500/55 + Child Dental |
01/01/2024 | Summary | SBC |
|
Blue Shield Access+ Silver 70 HMO 2500/55 + Child Dental INF |
01/01/2024 | SBC | |
|
Trio HMO Network |
|||
|
Blue Shield Trio Platinum 90 HMO 0/20 + Child Dental |
01/01/2024 | Summary | SBC |
|
Blue Shield Trio Platinum 90 HMO 0/20 + Child Dental INF |
01/01/2024 | SBC | |
|
Blue Shield Trio Gold 80 HMO 250/35 + Child Dental |
01/01/2024 | Summary | SBC |
|
Blue Shield Trio Gold 80 HMO 250/35 + Child Dental INF |
01/01/2024 | SBC | |
|
Blue Shield Trio Silver 70 HMO 2500/55 + Child Dental |
01/01/2024 | Summary | SBC |
|
Blue Shield Trio Silver 70 HMO 2500/55 + Child Dental INF |
01/01/2024 | SBC | |
|
Blue Shield Bronze Trio HMO 7000/70 + Child Dental |
01/01/2024 | Summary | SBC |
|
Blue Shield Bronze Trio HMO 7000/70 + Child Dental INF |
01/01/2024 | SBC | |
|
2024 Medical PPO Mirror Package |
|||
|
Blue Shield Platinum 90 PPO 0/15 + Child Dental |
01/01/2024 | Summary | SBC |
|
Blue Shield Platinum 90 PPO 0/15 + Child Dental INF |
01/01/2024 | SBC | |
|
Blue Shield Gold 80 PPO 350/25 + Child Dental |
01/01/2024 | Summary | SBC |
|
Blue Shield Gold 80 PPO 350/25 + Child Dental INF |
01/01/2024 | SBC | |
|
Blue Shield Silver 70 PPO 2500/55 + Child Dental |
01/01/2024 | Summary | SBC |
|
Blue Shield Silver 70 PPO 2500/55 + Child Dental INF |
01/01/2024 | SBC | |
|
Blue Shield Silver 70 HDHP PPO 2300/30% + Child Dental Alt |
01/01/2024 | Summary | SBC |
|
Blue Shield Silver 70 HDHP PPO 2300/30% + Child Dental Alt INF |
01/01/2024 | SBC | |
|
Blue Shield Bronze 60 PPO 6300/60 + Child Dental |
01/01/2024 | Summary | SBC |
|
Blue Shield Bronze 60 PPO 6300/60 + Child Dental INF |
01/01/2024 | SBC | |
|
Blue Shield Bronze 60 HDHP PPO 7500/0% + Child Dental Alt |
01/01/2024 | Summary | SBC |
|
Blue Shield Bronze 60 HDHP PPO 7500/0% + Child Dental Alt INF |
01/01/2024 | SBC | |
|
2024 Infertility Riders |
|||
|
Infertility Rider for HMO Plans |
01/01/2024 | Summary | |
|
Infertility Rider for PPO Plans |
01/01/2024 | Summary | |
|
Infertility Rider for HDHP Plans |
01/01/2024 | Summary | |
|
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 INF |
01/01/2023 | SBC | |
|
Gold Tandem PPO 500/30 OffEx |
01/01/2023 | Summary | SBC |
|
Gold Tandem PPO 500/30 OffEx INF |
01/01/2023 | SBC | |
|
Gold Tandem PPO 750/30 OffEx |
01/01/2023 | Summary | SBC |
|
Gold Tandem PPO 750/30 OffEx INF |
01/01/2023 | SBC | |
|
Gold Tandem PPO 1000/35 OffEx |
01/01/2023 | Summary | SBC |
|
Gold Tandem PPO 1000/35 OffEx INF |
01/01/2023 | SBC | |
|
Gold Tandem PPO Savings 1750/15% HDHP PrevRx OffEx |
01/01/2023 | Summary | SBC |
|
Gold Tandem PPO Savings 1750/15% HDHP PrevRx OffEx INF |
01/01/2023 | SBC | |
|
Silver Tandem PPO 2000/60 OffEx |
01/01/2023 | Summary | SBC |
|
Silver Tandem PPO 2000/60 OffEx INF |
01/01/2023 | SBC | |
|
Silver Tandem PPO 2350/65 OffEx |
01/01/2023 | Summary | SBC |
|
Silver Tandem PPO 2350/65 OffEx INF |
01/01/2023 | SBC | |
|
Silver Tandem PPO 2550/70 OffEx |
01/01/2023 | Summary | SBC |
|
Silver Tandem PPO 2550/70 OffEx INF |
01/01/2023 | SBC | |
|
Silver Tandem PPO Savings 2300/25% OffEx |
01/01/2023 | Summary | SBC |
|
Silver Tandem PPO Savings 2300/25% OffEx INF |
01/01/2023 | SBC | |
|
Silver Tandem PPO Savings 2600/35% HDHP PrevRx OffEx |
01/01/2023 | Summary | SBC |
|
Silver Tandem PPO Savings 2600/35% HDHP PrevRx OffEx INF |
01/01/2023 | SBC | |
|
Bronze Tandem PPO 5500/65 OffEx |
01/01/2023 | Summary | SBC |
|
Bronze Tandem PPO 5500/65 OffEx INF |
01/01/2023 | SBC | |
|
Bronze Tandem PPO 6250/65 OffEx |
01/01/2023 | Summary | SBC |
|
Bronze Tandem PPO 6250/65 OffEx INF |
01/01/2023 | SBC | |
|
Bronze Tandem PPO 6500/70 OffEx |
01/01/2023 | Summary | SBC |
|
Bronze Tandem PPO 6500/70 OffEx INF |
01/01/2023 | SBC | |
|
Bronze Tandem PPO 6850/55 OffEx |
01/01/2023 | Summary | SBC |
|
Bronze Tandem PPO 6850/55 OffEx INF |
01/01/2023 | SBC | |
|
Bronze Tandem PPO 7500/65 OffEx |
01/01/2023 | Summary | SBC |
|
Bronze Tandem PPO 7500/65 OffEx INF |
01/01/2023 | SBC | |
|
Bronze Tandem PPO Savings 5700/40% OffEx |
01/01/2023 | Summary | SBC |
|
Bronze Tandem PPO Savings 5700/40% OffEx INF |
01/01/2023 | SBC | |
|
Bronze Tandem PPO Savings 7000 OffEx |
01/01/2023 | Summary | SBC |
|
Bronze Tandem PPO Savings 7000 OffEx INF |
01/01/2023 | SBC | |
|
Virtual Blue Tandem PPO Network |
|||
|
Virtual Blue Gold Tandem PPO 1500/45 OffEx |
01/01/2023 | Summary | SBC |
|
Virtual Blue Gold Tandem PPO 1500/45 OffEx INF |
01/01/2023 | SBC | |
|
Virtual Blue Bronze Tandem PPO 7500/75 OffEx |
01/01/2023 | Summary | SBC |
|
Virtual Blue Bronze Tandem PPO 7500/75 OffEx INF |
01/01/2023 | SBC | |
|
2023 Medical HMO Mirror Package |
|||
|
Access+ HMO Network |
|||
|
Blue Shield Access+ Platinum 90 HMO 0/20 + Child Dental [New 7/1/2023] |
07/01/2023 | Summary | SBC |
|
Blue Shield Access+ Platinum 90 HMO 0/20 + Child Dental INF [New 7/1/2023] |
07/01/2023 | SBC | |
|
Blue Shield Access+ Gold 80 HMO 250/35 + Child Dental [New 7/1/2023] |
07/01/2023 | Summary | SBC |
|
Blue Shield Access+ Gold 80 HMO 250/35 + Child Dental INF [New 7/1/2023] |
07/01/2023 | SBC | |
|
Blue Shield Access+ Silver 70 HMO 2500/55 + Child Dental [New 7/1/2023] |
07/01/2023 | Summary | SBC |
|
Blue Shield Access+ Silver 70 HMO 2500/55 + Child Dental INF [New 7/1/2023] |
07/01/2023 | SBC | |
|
Trio HMO Network |
|||
|
Blue Shield Trio Platinum 90 HMO 0/20 + Child Dental |
01/01/2023 | Summary | SBC |
|
Blue Shield Trio Platinum 90 HMO 0/20 + Child Dental INF |
01/01/2023 | SBC | |
|
Blue Shield Trio Gold 80 HMO 250/35 + Child Dental |
01/01/2023 | Summary | SBC |
|
Blue Shield Trio Gold 80 HMO 250/35 + Child Dental INF |
01/01/2023 | SBC | |
|
Blue Shield Trio Silver 70 HMO 2500/55 + Child Dental |
01/01/2023 | Summary | SBC |
|
Blue Shield Trio Silver 70 HMO 2500/55 + Child Dental INF |
01/01/2023 | SBC | |
|
Blue Shield Bronze Trio HMO 7000/70 + Child Dental [New 7/1/2023] |
07/01/2023 | Summary | SBC |
|
Blue Shield Bronze Trio HMO 7000/70 + Child Dental INF [New 7/1/2023] |
07/01/2023 | SBC | |
|
2023 Medical PPO Mirror Package |
|||
|
Blue Shield Platinum 90 PPO 0/15 + Child Dental |
01/01/2023 | Summary | SBC |
|
Blue Shield Platinum 90 PPO 0/15 + Child Dental INF |
01/01/2023 | SBC | |
|
Blue Shield Gold 80 PPO 350/25 + Child Dental |
01/01/2023 | Summary | SBC |
|
Blue Shield Gold 80 PPO 350/25 + Child Dental INF |
01/01/2023 | SBC | |
|
Blue Shield Silver 70 PPO 2500/55 + Child Dental |
01/01/2023 | Summary | SBC |
|
Blue Shield Silver 70 PPO 2500/55 + Child Dental INF |
01/01/2023 | SBC | |
|
Blue Shield Silver Full PPO Savings 2300/25% + Child Dental [New 7/1/2023] |
07/01/2023 | Summary | SBC |
|
Blue Shield Silver Full PPO Savings 2300/25% + Child Dental INF [New 7/1/2023] |
07/01/2023 | SBC | |
|
Blue Shield Bronze 60 PPO 6300/65 + Child Dental |
01/01/2023 | Summary | SBC |
|
Blue Shield Bronze 60 PPO 6300/65 + Child Dental INF |
01/01/2023 | SBC | |
|
Blue Shield Bronze Full PPO Savings 7000 + Child Dental [New 7/1/2023] |
07/01/2023 | Summary | SBC |
|
Blue Shield Bronze Full PPO Savings 7000 + Child Dental INF [New 7/1/2023] |
07/01/2023 | SBC | |
|
2023 Infertility Riders |
|||
|
Infertility Rider for HMO Plans |
01/01/2023 | Summary | |
|
Infertility Rider for PPO Plans |
01/01/2023 | Summary | |
|
Infertility Rider for HDHP Plans |
01/01/2023 | Summary |
| Form Name | Effective Date | Download Form |
|---|---|---|
|
General Information |
||
|
Small Business Medical Sales Guide 7.24 |
07/01/2024 | Download |
|
Small Business Medical Sales Guide 4.24 |
04/01/2024 | Download |
|
Small Business Medical Sales Guide 1.24 |
01/01/2024 | Download |
|
Underwriting Guidelines 1.24 |
01/01/2024 | Download |
|
Helpful Information & Resources Flyer |
04/01/2024 | Download |
|
How to Print or Order your ID Card |
01/01/2022 | Download |
|
Online and Mobile Tools |
09/01/2023 | Download |
|
Pediatric Dental & Vision FAQ |
04/01/2024 | Download |
|
Premium Only Plan by HealthEquity |
10/01/2023 | Download |
|
Producer Agreement 2024 |
01/01/2024 | Download |
|
Relaxed Participation Guidelines through 12.24 Effective Date |
01/01/2024 | Download |
|
Specialty Bundle & Save Flyer |
01/01/2024 | Download |
|
Specialty Overview |
01/01/2024 | Download |
|
Specialty Quick Facts |
01/01/2022 | Download |
|
Specialty Sales Guide 7.24 |
07/01/2024 | Download |
|
Specialty Sales Guide 4.24 |
04/01/2024 | Download |
|
Specialty Sales Guide 1.24 |
01/01/2024 | Download |
|
Why Blue Shield of California Employer Brochure |
01/01/2022 | Download |
|
Medical |
||
|
Medical Plans at a Glance 1.24 |
01/02/2024 | Download |
|
Medical Plans Cheat Sheet 1.24 |
01/01/2024 | Download |
|
Accessing Care - Care When You Need It Flyer |
09/01/2023 | Download |
|
BlueCard and Away from Home Care for HMO Members Flyer |
01/01/2024 | Download |
|
Blue Card Program for Care Outside California |
01/01/2024 | Download |
|
Epic Hearing Discounts |
09/01/2023 | Download |
|
Fitness Your Way Flyer |
09/01/2023 | Download |
|
LifeReferrals 24/7 Flyer |
02/01/2024 | Download |
|
LifeReferrals Critical Incident Flyer |
02/01/2024 | Download |
|
LifeReferrals Workplace Support Flyer |
02/01/2024 | Download |
|
Mail Service Prescriptions Flyer |
09/01/2023 | Download |
|
Mail Service Order Form |
01/01/2024 | Download |
|
Maven Maternity Flyer |
09/01/2023 | Download |
|
MyStrength for Trio & Tandem Flyer |
01/01/2022 | Download |
|
NurseHelp Employee Flyer |
01/01/2024 | Download |
|
Online Provider Search Instructions |
01/01/2024 | Download |
|
Standard Prescription Drug Formulary 11.22 |
07/01/2023 | Download |
|
Specialty Drug List for Standard Drug Formulary |
07/01/2023 | Download |
|
Preventive Health Guidelines |
01/01/2024 | 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 1.24 |
01/01/2024 | Download |
|
Spectrum Tiered Pharmacy Network Directory |
07/01/2023 | Download |
|
Spectrum Tiered Pharmacy Network Flyer |
07/01/2023 | Download |
|
Total Health and Wellness - Programs & Services for Blue Shield Members |
09/01/2023 | Download |
|
Treatment Cost Estimator PPO Member Flyer |
01/01/2022 | Download |
|
Trio HMO Brochure |
06/01/2022 | Download |
|
Trio HMO Network Brochure |
10/01/2023 | Download |
|
Urgent Care Flyer |
01/01/2024 | Download |
|
Vaccines at Retail Pharmacies |
09/01/2023 | Download |
|
Wellness Discounts for Blue Shield Members |
09/01/2023 | Download |
|
Wellvolution Flyer |
09/01/2023 | Download |
|
Wellvolution Ginger Flyer |
09/01/2023 | Download |
|
Wellvolution Headspace Flyer |
09/01/2023 | Download |
|
Why Switch to Tandem Flyer |
01/01/2022 | Download |
|
Why Switch to Trio Flyer |
01/01/2022 | Download |
|
Women's Preventive Health |
01/01/2024 | Download |
|
Dental |
||
|
Dental Mapping for Discontinued Plans |
01/01/2024 | Download |
|
Caries Risk Management & Assessment |
02/01/2024 | Download |
|
Dental Implant FAQ |
01/01/2024 | Download |
|
Dental Network Map |
02/01/2024 | Download |
|
Find a Dental or Vision Provider of Your Choice |
04/01/2024 | Download |
|
Dentist Nomination Form |
02/01/2024 | Download |
|
Guide to Managing your Dental Plan Online |
01/01/2024 | Download |
|
Member Guide to Orthodontic Coverage |
01/01/2024 | Download |
|
Vision |
||
|
Managing Your Vision Plan Online |
01/01/2024 | Download |
|
Vision Network Map |
02/01/2024 | Download |
|
Find a Dental or Vision Provider of Your Choice |
04/01/2024 | Download |
|
Life |
||
|
Basic Life/AD&D Quick Match Program Guidelines |
02/01/2024 | Download |
|
LifeReferrals 24/7 - Beneficiary Assistance Program |
02/01/2024 | Download |
|
Travel Assistance Program Brochure |
02/01/2024 | Download |
