Form Name | Effective Date | Download Form |
---|---|---|
New Group Submission |
||
New Group Submission Checklist [new effective 9/4/2020] |
09/04/2020 | 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 | |
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 | |
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 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 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 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 |
01/01/2019 | ||
Preferred Vision Plans (12/12/24) |
01/01/2019 | Summary | |
Preferred Vision Plus 0/0/150/120 |
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 | |
|
Form Name | Effective Date | Download Form |
---|---|---|
General Information |
||
Sales Guide 4.21 |
04/01/2021 | Download |
Sales Guide 1.21 |
01/01/2021 | Download |
Sales Guide 10.20 |
10/01/2020 | Download |
Underwriting Guidelines 1.21 |
01/01/2021 | Download |
Underwriting Guidelines 10.20 |
10/01/2020 | 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 |
Relaxed Participation Guidelines through 1.21 Effective Date |
06/01/2020 | 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 1/1/2021] |
01/01/2021 | Download |