CaliforniaChoice

Form Name	Effective Date	Download Form
New Group Submission
CalChoice Medical Submission Checklist	01/01/2020	Download
CalChoice Dental/Life Submission Checklist	01/01/2020	Download
Employer Application 10.20 to 12.20 Effective Dates	10/01/2020	Download
Employer Application 1.21 Effective Dates	01/01/2021	Download
ACH Payment Form Effective 4.20	04/01/2020	Download
Owner Partner Statement Form	01/01/2020	Download
Case Submission Acknowledgement (for groups submitted after the requested effective date)	01/01/2020	Download
Common Ownership Statement	01/01/2020	Download
Full FSA Election Form	01/01/2020	Download
Group Size Attestation	01/01/2020	Download
Prior Carrier Cancellation Letter Template	01/01/2020	Download
In Force Group Forms
Employee Termination Notification	01/01/2019	Download
Employer Change Request Form 10.20 to 12.20 Effective Dates	10/01/2020	Download
Employer Change Request Form 1.21 Effective Dates	01/01/2021	Download
Employer Group Contact Change	01/01/2019	Download
Employer In Force Group Dental Application 7.20	07/01/2020	Download
Employer In Force Group Voluntary Vision Application 1.20	01/01/2020	Download
Employer Recertification Agreement 1.20 to 6.20 Effective Dates	01/01/2020	Download
Exception Review Request Form	01/01/2019	Download
Group COBRA Direct Billing Contract	01/01/2020	Download
New Hire Enrollment Quote Request	01/01/2020	Download
Administration
Employer Administrative Guide	07/01/2020	Download
Employer Program Guide 10.20 to 12.20 Effective Dates	10/01/2020	Download

Form Name	Effective Date	Download Form
Enrollment and Change Forms
Employee Enrollment Form 10.20 to 12.20 Effective Dates	10/01/2020	Download
Employee Enrollment Form 1.21 Effective Dates	01/01/2021	Download
Employee Change Request Form 10.20 to 12.20 Effective Dates	10/01/2020	Download
Employee Change Request Form 1.21 Effective Dates	01/01/2021	Download
Disabled Dependent Certification Form	01/01/2020	Download
Affidavit of Domestic Partnership	01/01/2020	Download
COBRA Forms
COBRA Enrollment Application	01/01/2020	Download
Claim Forms
RX Claim Form - Anthem Express Scripts		Download
RX Claim Form - Health Net		Download
RX Claim Form - Sharp		Download
RX Claim Form - UHC		Download
RX by Mail Claim Form - Anthem		Download
RX by Mail Claim Form - Health Net		Download
RX by Mail Claim Form - Kaiser		Download
RX by Mail Claim Form - Sharp		Download
RX by Mail Claim Form - UHC		Download

Form Name	Effective Date	Download Form
2021 Medical Plan Benefit Summary Booklets
January - March 2021 Effective Dates
All Tiers Benefit Summaries 1.21 - 3.21 Effective Dates	01/01/2021	Summary
Platinum Benefit Summaries 1.21 - 3.21 Effective Dates	01/01/2021	Summary
Platinum/Gold Benefit Summaries 1.21 - 3.21 Effective Dates	01/01/2021	Summary
Platinum/Gold/Silver Benefit Summaries 1.21 - 3.21 Effective Dates	01/01/2021	Summary
Gold Benefit Summaries 1.21 - 3.21 Effective Dates	01/01/2021	Summary
Gold/Silver Benefit Summaries 1.21 - 3.21 Effective Dates	01/01/2021	Summary
Gold/Silver/Bronze Benefit Summaries 1.21 - 3.21 Effective Dates	01/01/2021	Summary
Silver Benefit Summaries 1.21 - 3.21 Effective Dates	01/01/2021	Summary
Silver/Bronze Benefit Summaries 1.21 - 3.21 Effective Dates	01/01/2021	Summary
Bronze Benefit Summaries 1.21 - 3.21 Effective Dates	01/01/2021	Summary
2021 Medical HMO SBCs
Anthem HMO
Anthem Blue Cross Platinum Select HMO A	01/01/2021		SBC
Anthem Blue Cross Gold Select HMO A	01/01/2021		SBC
Anthem Blue Cross Gold CaliforniaCare HMO B	01/01/2021		SBC
Anthem Blue Cross Silver Select HMO A	01/01/2021		SBC
Anthem Blue Cross Silver CaliforniaCare HMO B	01/01/2021		SBC
Health Net HMO
Health Net Platinum WholeCare HMO C	01/01/2021		SBC
Health Net Platinum Salud HMO D	01/01/2021		SBC
Health Net Platinum Full Network HMO E	01/01/2021		SBC
Health Net Platinum Wholecare HMO F	01/01/2021		SBC
Health Net Platinum Salud HMO G	01/01/2021		SBC
Health Net Platinum Full Network HMO H	01/01/2021		SBC
Health Net Gold WholeCare HMO A	01/01/2021		SBC
Health Net Gold WholeCare HMO B	01/01/2021		SBC
Health Net Gold WholeCare HMO C	01/01/2021		SBC
Health Net Gold Salud HMO D	01/01/2021		SBC
Health Net Gold Full Network HMO E	01/01/2021		SBC
Health Net Gold Full Network HMO F	01/01/2021		SBC
Health Net Silver WholeCare HMO A	01/01/2021		SBC
Health Net Silver CommunityCare HMO C	01/01/2021		SBC
Health Net Bronze CommunityCare HMO A	01/01/2021		SBC
Kaiser Permanente HMO
Kaiser Platinum HMO A	01/01/2021		SBC
Kaiser Platinum HMO B	01/01/2021		SBC
Kaiser Gold HMO B	01/01/2021		SBC
Kaiser Gold HMO C	01/01/2021		SBC
Kaiser Gold HMO D	01/01/2021		SBC
Kaiser Silver HMO A	01/01/2021		SBC
Kaiser Silver HMO B	01/01/2021		SBC
Kaiser Silver HMO C	01/01/2021		SBC
Kaiser Silver HMO D (HSA Eligible)	01/01/2021		SBC
Kaiser Silver HMO E	01/01/2021		SBC
Kaiser Bronze HMO A	01/01/2021		SBC
Kaiser Bronze HMO B	01/01/2021		SBC
Kaiser Bronze HMO C (HSA Eligible)	01/01/2021		SBC
Sharp HMO
Sharp Platinum Premier HMO A	01/01/2021		SBC
Sharp Platinum Performance HMO B	01/01/2021		SBC
Sharp Platinum Premier HMO C	01/01/2021		SBC
Sharp Gold Performance HMO A	01/01/2021		SBC
Sharp Gold Premier HMO B	01/01/2021		SBC
Sharp Gold Performance HMO D	01/01/2021		SBC
Sharp Silver Premier HMO A	01/01/2021		SBC
Sharp Silver Performance HMO B	01/01/2021		SBC
Sharp Silver Premier HMO C	01/01/2021		SBC
Sharp Bronze Premier HMO A	01/01/2021		SBC
Sharp Bronze Performance HMO B (HSA Eligible)	01/01/2021		SBC
Sutter Health Plus HMO
Sutter Health Plus Platinum HMO A	01/01/2021		SBC
Sutter Health Plus Platinum HMO B	01/01/2021		SBC
Sutter Health Plus Gold HMO A	01/01/2021		SBC
Sutter Health Plus Gold HMO B	01/01/2021		SBC
Sutter Health Plus Silver HMO B	01/01/2021		SBC
Sutter Health Plus Silver HMO C (HSA Eligible)	01/01/2021		SBC
Sutter Health Plus Bronze HMO A	01/01/2021		SBC
Sutter Health Plus Bronze HMO B (HSA Eligible)	01/01/2021		SBC
UnitedHealthcare HMO
UHC Platinum SignatureValue HMO A	01/01/2021		SBC
UHC Platinum Alliance HMO C	01/01/2021		SBC
UHC Platinum Advantage HMO D	01/01/2021		SBC
UHC Platinum SignatureValue HMO E	01/01/2021		SBC
UHC Platinum Advantage HMO F	01/01/2021		SBC
UHC Platinum Alliance HMO G	01/01/2021		SBC
UHC Gold SignatureValue HMO A	01/01/2021		SBC
UHC Gold Alliance HMO B	01/01/2021		SBC
UHC Gold Advantage HMO E	01/01/2021		SBC
UHC Gold SignatureValue HMO F	01/01/2021		SBC
UHC Gold Alliance HMO G	01/01/2021		SBC
UHC Gold SignatureValue HMO H	01/01/2021		SBC
UHC Gold Advantage HMO I	01/01/2021		SBC
UHC Gold Alliance HMO J	01/01/2021		SBC
UHC Gold Advantage HMO K	01/01/2021		SBC
UHC Silver SignatureValue HMO A	01/01/2021		SBC
UHC Silver Advantage HMO B	01/01/2021		SBC
UHC Silver Alliance HMO E	01/01/2021		SBC
Western Health Advantage HMO
Western Health Platinum HMO A	01/01/2021		SBC
Western Health Platinum HMO B	01/01/2021		SBC
Western Health Platinum HMO C	01/01/2021		SBC
Western Health Gold HMO A	01/01/2021		SBC
Western Health Gold HMO B	01/01/2021		SBC
Western Health Gold HMO C	01/01/2021		SBC
Western Health Gold HMO D (HSA Eligible)	01/01/2021		SBC
Western Health Silver HMO A	01/01/2021		SBC
Western Health Silver HMO B	01/01/2021		SBC
Western Health Silver HMO C (HSA Eligible)	01/01/2021		SBC
Western Health Bronze HMO B	01/01/2021		SBC
Western Health Bronze HMO C (HSA Eligible)	01/01/2021		SBC
2021 Medical EPO SBCs
Anthem Blue Cross EPO
Anthem Blue Cross Silver EPO A	01/01/2021		SBC
Anthem Blue Cross Silver EPO B (HSA Eligible)	01/01/2021		SBC
Anthem Blue Cross Bronze EPO A	01/01/2021		SBC
Oscar EPO
Oscar Platinum EPO A	01/01/2021		SBC
Oscar Platinum EPO B	01/01/2021		SBC
Oscar Gold EPO A	01/01/2021		SBC
Oscar Gold EPO B	01/01/2021		SBC
Oscar Gold EPO C	01/01/2021		SBC
Oscar Gold EPO D	01/01/2021		SBC
Oscar Silver EPO A (HSA Eligible)	01/01/2021		SBC
Oscar Silver EPO B	01/01/2021		SBC
Oscar Silver EPO C	01/01/2021		SBC
Oscar Silver EPO D	01/01/2021		SBC
Oscar Bronze EPO A (HSA Eligible)	01/01/2021		SBC
Oscar Bronze EPO B	01/01/2021		SBC
Oscar Bronze EPO C	01/01/2021		SBC
2021 Medical PPO SBCs
Anthem Blue Cross PPO
Anthem Blue Cross Gold Advantage PPO A	01/01/2021		SBC
Anthem Blue Cross Gold Select PPO B	01/01/2021		SBC
Anthem Blue Cross Gold Select PPO C	01/01/2021		SBC
Anthem Blue Cross Gold Select PPO D	01/01/2021		SBC
Anthem Blue Cross Gold PPO E	01/01/2021		SBC
Anthem Blue Cross Silver Advantage PPO A	01/01/2021		SBC
Anthem Blue Cross Silver Select PPO B	01/01/2021		SBC
Anthem Blue Cross Silver PPO C	01/01/2021		SBC
Anthem Blue Cross Bronze PPO A (HSA Eligible)	01/01/2021		SBC
Anthem Blue Cross Bronze Select PPO B (HSA Eligible)	01/01/2021		SBC
2020 Medical Plan Benefit Summary Booklets
January - April 2020 Effective Dates
All Tiers Benefit Summaries 1.20 - 4.20 Effective Dates	01/01/2020	Summary
Platinum Benefit Summaries 1.20 - 4.20 Effective Dates	01/01/2020	Summary
Platinum/Gold Benefit Summaries 1.20 - 4.20 Effective Dates	01/01/2020	Summary
Platinum/Gold/Silver Benefit Summaries 1.20 - 4.20 Effective Dates	01/01/2020	Summary
Gold Benefit Summaries 1.20 - 4.20 Effective Dates	01/01/2020	Summary
Gold/Silver Benefit Summaries 1.20 - 4.20 Effective Dates	01/01/2020	Summary
Silver Benefit Summaries 1.20 - 4.20 Effective Dates	01/01/2020	Summary
Silver/Bronze Benefit Summaries 1.20 - 4.20 Effective Dates	01/01/2020	Summary
Bronze Benefit Summaries 1.20 - 4.20 Effective Dates	01/01/2020	Summary
May - June 2020 Effective Dates
All Tiers Benefit Summaries 5.20 - 6.20 Effective Dates	05/01/2020	Summary
Platinum Benefit Summaries 5.20 - 6.20 Effective Dates	05/01/2020	Summary
Platinum/Gold Benefit Summaries 5.20 - 6.20 Effective Dates	05/01/2020	Summary
Platinum/Gold/Silver Benefit Summaries 5.20 - 6.20 Effective Dates	05/01/2020	Summary
Gold Benefit Summaries 5.20 - 6.20 Effective Dates	05/01/2020	Summary
Gold/Silver Benefit Summaries 5.20 - 6.20 Effective Dates	05/01/2020	Summary
Silver Benefit Summaries 5.20 - 6.20 Effective Dates	05/01/2020	Summary
Silver/Bronze Benefit Summaries 5.20 - 6.20 Effective Dates	05/01/2020	Summary
Bronze Benefit Summaries 5.20 - 6.20 Effective Dates	05/01/2020	Summary
July - September 2020 Effective Dates
All Tiers Benefit Summaries 7.20 - 9.20 Effective Dates	07/01/2020	Summary
Platinum Benefit Summaries 7.20 - 9.20 Effective Dates	07/01/2020	Summary
Platinum/Gold Benefit Summaries 7.20 - 9.20 Effective Dates	07/01/2020	Summary
Platinum/Gold/Silver Benefit Summaries 7.20 - 9.20 Effective Dates	07/01/2020	Summary
Gold Benefit Summaries 7.20 - 9.20 Effective Dates	07/01/2020	Summary
Gold/Silver Benefit Summaries 7.20 - 9.20 Effective Dates	07/01/2020	Summary
Gold/Silver/Bronze Benefit Summaries 7.20 - 9.20 Effective Dates	07/01/2020	Summary
Silver Benefit Summaries 7.20 - 9.20 Effective Dates	07/01/2020	Summary
Silver/Bronze Benefit Summaries 7.20 - 9.20 Effective Dates	07/01/2020	Summary
Bronze Benefit Summaries 7.20 - 9.20 Effective Dates	07/01/2020	Summary
October - December 2020 Effective Dates
All Tiers Benefit Summaries 10.20 - 12.20 Effective Dates	10/01/2020	Summary
Platinum Benefit Summaries 10.20 - 12.20 Effective Dates	10/01/2020	Summary
Platinum/Gold Benefit Summaries 10.20 - 12.20 Effective Dates	10/01/2020	Summary
Platinum/Gold/Silver Benefit Summaries 10.20 - 12.20 Effective Dates	10/01/2020	Summary
Gold Benefit Summaries 10.20 - 12.20 Effective Dates	10/01/2020	Summary
Gold/Silver Benefit Summaries 10.20 - 12.20 Effective Dates	10/01/2020	Summary
Gold/Silver/Bronze Benefit Summaries 10.20 - 12.20 Effective Dates	10/01/2020	Summary
Silver Benefit Summaries 10.20 - 12.20 Effective Dates	10/01/2020	Summary
Silver/Bronze Benefit Summaries 10.20 - 12.20 Effective Dates	10/01/2020	Summary
Bronze Benefit Summaries 10.20 - 12.20 Effective Dates	10/01/2020	Summary
2020 Medical HMO SBCs
Anthem HMO
Anthem Blue Cross Platinum Select HMO A	01/01/2020		SBC
Anthem Blue Cross Gold Select HMO A	01/01/2020		SBC
Anthem Blue Cross Gold CaliforniaCare HMO B	01/01/2020		SBC
Anthem Blue Cross Silver Select HMO A	01/01/2020		SBC
Anthem Blue Cross Silver CaliforniaCare HMO B	01/01/2020		SBC
Health Net HMO
Health Net Platinum WholeCare HMO C	01/01/2020		SBC
Health Net Platinum Salud HMO D	01/01/2020		SBC
Health Net Platinum Full Network HMO E	01/01/2020		SBC
Health Net Gold WholeCare HMO A	01/01/2020		SBC
Health Net Gold WholeCare HMO B	01/01/2020		SBC
Health Net Gold WholeCare HMO C	01/01/2020		SBC
Health Net Gold Salud HMO D	01/01/2020		SBC
Health Net Gold Full Network HMO E	01/01/2020		SBC
Health Net Gold Full Network HMO F	01/01/2020		SBC
Health Net Silver WholeCare HMO A	01/01/2020		SBC
Health Net Silver CommunityCare HMO C	01/01/2020		SBC
Health Net Bronze CommunityCare HMO A	01/01/2020		SBC
Kaiser Permanente HMO
Kaiser Platinum HMO A	01/01/2020		SBC
Kaiser Platinum HMO B	01/01/2020		SBC
Kaiser Gold HMO A	01/01/2020		SBC
Kaiser Gold HMO B	01/01/2020		SBC
Kaiser Silver HMO A	01/01/2020		SBC
Kaiser Silver HMO B	01/01/2020		SBC
Kaiser Silver HMO C	01/01/2020		SBC
Kaiser Silver HMO D (HSA Eligible)	01/01/2020		SBC
Kaiser Bronze HMO A	01/01/2020		SBC
Kaiser Bronze HMO C (HSA Eligible)	01/01/2020		SBC
Sharp HMO
Sharp Platinum Premier HMO A	01/01/2020		SBC
Sharp Platinum Performance HMO B	01/01/2020		SBC
Sharp Platinum Premier HMO C	01/01/2020		SBC
Sharp Gold Performance HMO A	01/01/2020		SBC
Sharp Gold Premier HMO B	01/01/2020		SBC
Sharp Gold Performance HMO D	01/01/2020		SBC
Sharp Silver Premier HMO A	01/01/2020		SBC
Sharp Silver Performance HMO B	01/01/2020		SBC
Sharp Silver Premier HMO C	01/01/2020		SBC
Sharp Bronze Premier HMO A	01/01/2020		SBC
Sharp Bronze Performance HMO B (HSA Eligible)	01/01/2020		SBC
Sutter Health Plus HMO
Sutter Health Plus Platinum HMO A	01/01/2020		SBC
Sutter Health Plus Platinum HMO B	01/01/2020		SBC
Sutter Health Plus Gold HMO A	01/01/2020		SBC
Sutter Health Plus Gold HMO B	01/01/2020		SBC
Sutter Health Plus Silver HMO B	01/01/2020		SBC
Sutter Health Plus Silver HMO C (HSA Eligible)	01/01/2020		SBC
Sutter Health Plus Bronze HMO A	01/01/2020		SBC
Sutter Health Plus Bronze HMO B (HSA Eligible)	01/01/2020		SBC
UnitedHealthcare HMO
UHC Platinum SignatureValue HMO A	01/01/2020		SBC
UHC Platinum Focus HMO B	01/01/2020		SBC
UHC Platinum Alliance HMO C	01/01/2020		SBC
UHC Gold SignatureValue HMO A	01/01/2020		SBC
UHC Gold Alliance HMO B	01/01/2020		SBC
UHC Gold Focus HMO C	01/01/2020		SBC
UHC Gold Advantage HMO E [new effective 10/1/2020]	10/01/2020		SBC
UHC Silver SignatureValue HMO A	01/01/2020		SBC
UHC Silver Advantage HMO B	01/01/2020		SBC
UHC Silver Alliance HMO C	01/01/2020		SBC
UHC Silver Focus HMO D	01/01/2020		SBC
UHC Bronze Alliance HMO A	01/01/2020		SBC
UHC Bronze Alliance HMO B (HSA Eligible)	01/01/2020		SBC
Western Health Advantage HMO
Western Health Platinum HMO A	01/01/2020		SBC
Western Health Platinum HMO B	01/01/2020		SBC
Western Health Gold HMO A	01/01/2020		SBC
Western Health Gold HMO B	01/01/2020		SBC
Western Health Gold HMO C	01/01/2020		SBC
Western Health Gold HMO D (HSA Eligible)	01/01/2020		SBC
Western Health Silver HMO A	01/01/2020		SBC
Western Health Silver HMO B	01/01/2020		SBC
Western Health Silver HMO C (HSA Eligible)	01/01/2020		SBC
Western Health Bronze HMO B	01/01/2020		SBC
Western Health Bronze HMO C (HSA Eligible)	01/01/2020		SBC
2020 Medical PPO and EPO SBCs
Anthem Blue Cross PPO and EPO
Anthem Blue Cross Gold Advantage PPO A	01/01/2020		SBC
Anthem Blue Cross Gold Select PPO B	01/01/2020		SBC
Anthem Blue Cross Gold Select PPO C	01/01/2020		SBC
Anthem Blue Cross Gold Select PPO D	01/01/2020		SBC
Anthem Blue Cross Gold PPO E [new effective 7/1/2020]	07/01/2020		SBC
Anthem Blue Cross Silver Advantage PPO A	01/01/2020		SBC
Anthem Blue Cross Silver Select PPO B	01/01/2020		SBC
Anthem Blue Cross Silver PPO C [new effective 7/1/2020]	07/01/2020		SBC
Anthem Blue Cross Silver EPO A	01/01/2020		SBC
Anthem Blue Cross Silver EPO B (HSA Eligible)	01/01/2020		SBC
Anthem Blue Cross Bronze PPO A (HSA Eligible) [new effective 7/1/2020]	07/01/2020		SBC
Anthem Blue Cross Bronze Select PPO B (HSA Eligible) [new effective 7/1/2020]	07/01/2020		SBC
Anthem Blue Cross Bronze EPO A [plan discontinued 4/30/2020]	01/01/2020		SBC
Anthem Blue Cross Bronze EPO A [updated benefits for groups effective 5/1/2020 and later]	05/01/2020		SBC
Oscar EPO
Oscar Platinum EPO A	01/01/2020		SBC
Oscar Platinum EPO B	01/01/2020		SBC
Oscar Gold EPO A	01/01/2020		SBC
Oscar Gold EPO B	01/01/2020		SBC
Oscar Gold EPO C	01/01/2020		SBC
Oscar Gold EPO D	01/01/2020		SBC
Oscar Silver EPO A (HSA Eligible)	01/01/2020		SBC
Oscar Silver EPO B	01/01/2020		SBC
Oscar Silver EPO C	01/01/2020		SBC
Oscar Silver EPO D [new effective 10/1/2020]	10/01/2020		SBC
Oscar Bronze EPO A (HSA Eligible)	01/01/2020		SBC
Oscar Bronze EPO B	01/01/2020		SBC
Oscar Bronze EPO C [new effective 10/1/2020]	10/01/2020		SBC
2019 Medical Plan Benefit Summary Booklets
January - March 2019 Effective Dates
All Tiers Benefit Summaries 1.19 - 3.19 Effective Dates	01/01/2019	Summary
Platinum Benefit Summaries 1.19 - 3.19 Effective Dates	01/01/2019	Summary
Platinum/Gold Benefit Summaries 1.19 - 3.19 Effective Dates	01/01/2019	Summary
Platinum/Gold/Silver Benefit Summaries 1.19 - 3.19 Effective Dates	01/01/2019	Summary
Gold Benefit Summaries 1.19 - 3.19 Effective Dates	01/01/2019	Summary
Gold/Silver Benefit Summaries 1.19 - 3.19 Effective Dates	01/01/2019	Summary
Silver Benefit Summaries 1.19 - 3.19 Effective Dates	01/01/2019	Summary
Silver/Bronze Benefit Summaries 1.19 - 3.19 Effective Dates	01/01/2019	Summary
Bronze Benefit Summaries 1.19 - 3.19 Effective Dates	01/01/2019	Summary
April - August 2019 Effective Dates
All Tiers Benefit Summaries 4.19 - 8.19 Effective Dates	04/01/2019	Summary
Platinum Benefit Summaries 4.19 - 8.19 Effective Dates	04/01/2019	Summary
Platinum/Gold Benefit Summaries 4.19 - 8.19 Effective Dates	04/01/2019	Summary
Platinum/Gold/Silver Benefit Summaries 4.19 - 8.19 Effective Dates	04/01/2019	Summary
Gold Benefit Summaries 4.19 - 8.19 Effective Dates	04/01/2019	Summary
Gold/Silver Benefit Summaries 4.19 - 8.19 Effective Dates	04/01/2019	Summary
Silver Benefit Summaries 4.19 - 8.19 Effective Dates	04/01/2019	Summary
Silver/Bronze Benefit Summaries 4.19 - 8.19 Effective Dates	04/01/2019	Summary
Bronze Benefit Summaries 4.19 - 8.19 Effective Dates	04/01/2019	Summary
September 2019 Effective Dates
All Tiers Benefit Summaries 9.19 Effective Dates	09/01/2019	Summary
Platinum Benefit Summaries 9.19 Effective Dates	09/01/2019	Summary
Platinum/Gold Benefit Summaries 9.19 Effective Dates	09/01/2019	Summary
Platinum/Gold/Silver Benefit Summaries 9.19 Effective Dates	09/01/2019	Summary
Gold Benefit Summaries 9.19 Effective Dates	09/01/2019	Summary
Gold/Silver Benefit Summaries 9.19 Effective Dates	09/01/2019	Summary
Silver Benefit Summaries 9.19 Effective Dates	09/01/2019	Summary
Silver/Bronze Benefit Summaries 9.19 Effective Dates	09/01/2019	Summary
Bronze Benefit Summaries 9.19 Effective Dates	09/01/2019	Summary
October - December 2019 Effective Dates
All Tiers Benefit Summaries 10.19 - 12.19 Effective Dates	10/01/2019	Summary
Platinum Benefit Summaries 10.19 - 12.19 Effective Dates	10/01/2019	Summary
Platinum/Gold Benefit Summaries 10.19 - 12.19 Effective Dates	10/01/2019	Summary
Platinum/Gold/Silver Benefit Summaries 10.19 - 12.19 Effective Dates	10/01/2019	Summary
Gold Benefit Summaries 10.19 - 12.19 Effective Dates	10/01/2019	Summary
Gold/Silver Benefit Summaries 10.19 - 12.19 Effective Dates	10/01/2019	Summary
Silver Benefit Summaries 10.19 - 12.19 Effective Dates	10/01/2019	Summary
Silver/Bronze Benefit Summaries 10.19 - 12.19 Effective Dates	10/01/2019	Summary
Bronze Benefit Summaries 10.19 - 12.19 Effective Dates	10/01/2019	Summary
2019 Medical HMO and HSP SBCs
Anthem HMO
Anthem Blue Cross Platinum Select HMO A	01/01/2019		SBC
Anthem Blue Cross Platinum Select HMO A [Benefit Update 10.19]	10/01/2019		SBC
Anthem Blue Cross Gold Select HMO A	01/01/2019		SBC
Anthem Blue Cross Gold Select HMO A [Benefit Update 10.19]	10/01/2019		SBC
Anthem Blue Cross Gold CaliforniaCare HMO B [New 9.19]	09/01/2019		SBC
Anthem Blue Cross Silver Select HMO A	01/01/2019		SBC
Anthem Blue Cross Silver Select HMO A [Benefit Update 10.19]	10/01/2019		SBC
Anthem Blue Cross Silver CaliforniaCare HMO B [New 9.19]	09/01/2019		SBC
Health Net HMO and HSP
Health Net Platinum WholeCare HMO C	01/01/2019		SBC
Health Net Platinum Salud HMO D	01/01/2019		SBC
Health Net Platinum SmartCare HMO E	01/01/2019		SBC
Health Net Gold WholeCare HMO A	01/01/2019		SBC
Health Net Gold WholeCare HMO B	01/01/2019		SBC
Health Net Gold WholeCare HMO C	01/01/2019		SBC
Health Net Gold Salud HMO D	01/01/2019		SBC
Health Net Gold SmartCare HMO E	01/01/2019		SBC
Health Net Silver WholeCare HMO A	01/01/2019		SBC
Health Net Silver CommunityCare HMO B	01/01/2019		SBC
Health Net Silver PureCare HSP A	01/01/2019		SBC
Health Net Bronze PureCare HSP A	01/01/2019		SBC
Kaiser Permanente HMO
Kaiser Platinum HMO A	01/01/2019		SBC
Kaiser Platinum HMO B	01/01/2019		SBC
Kaiser Gold HMO A	01/01/2019		SBC
Kaiser Gold HMO B	01/01/2019		SBC
Kaiser Silver HMO A	01/01/2019		SBC
Kaiser Silver HMO B	01/01/2019		SBC
Kaiser Silver HMO C	01/01/2019		SBC
Kaiser Silver HMO D (HSA Eligible)	01/01/2019		SBC
Kaiser Bronze HMO A	01/01/2019		SBC
Kaiser Bronze HMO C (HSA Eligible)	01/01/2019		SBC
Sharp HMO
Sharp Platinum Premier HMO A	01/01/2019		SBC
Sharp Platinum Performance HMO B	01/01/2019		SBC
Sharp Platinum Premier HMO C	01/01/2019		SBC
Sharp Gold Performance HMO A	01/01/2019		SBC
Sharp Gold Premier HMO B	01/01/2019		SBC
Sharp Gold Performance HMO D	01/01/2019		SBC
Sharp Silver Premier HMO A	01/01/2019		SBC
Sharp Silver Performance HMO B	01/01/2019		SBC
Sharp Silver Premier HMO C	01/01/2019		SBC
Sharp Bronze Premier HMO A	01/01/2019		SBC
Sharp Bronze Performance HMO B (HSA Eligible)	01/01/2019		SBC
Sutter Health Plus HMO
Sutter Health Plus Platinum HMO A	01/01/2019		SBC
Sutter Health Plus Platinum HMO B	01/01/2019		SBC
Sutter Health Plus Gold HMO A	01/01/2019		SBC
Sutter Health Plus Gold HMO B	01/01/2019		SBC
Sutter Health Plus Silver HMO B	01/01/2019		SBC
Sutter Health Plus Silver HMO C (HSA Eligible)	01/01/2019		SBC
Sutter Health Plus Bronze HMO A	01/01/2019		SBC
Sutter Health Plus Bronze HMO B (HSA Eligible)	01/01/2019		SBC
UnitedHealthcare HMO
UHC Platinum SignatureValue HMO A	01/01/2019		SBC
UHC Platinum Focus HMO B	01/01/2019		SBC
UHC Platinum Advantage HMO C	01/01/2019		SBC
UHC Gold SignatureValue HMO A	01/01/2019		SBC
UHC Gold Alliance HMO B	01/01/2019		SBC
UHC Gold Focus HMO C	01/01/2019		SBC
UHC Gold Advantage HMO D	01/01/2019		SBC
UHC Silver SignatureValue HMO A	01/01/2019		SBC
UHC Silver Advantage HMO B	01/01/2019		SBC
UHC Silver Alliance HMO C	01/01/2019		SBC
UHC Silver Focus HMO D	01/01/2019		SBC
UHC Bronze Alliance HMO B (HSA Eligible)	01/01/2019		SBC
Western Health Advantage HMO
Western Health Platinum HMO A	01/01/2019		SBC
Western Health Platinum HMO B	01/01/2019		SBC
Western Health Gold HMO A	01/01/2019		SBC
Western Health Gold HMO B	01/01/2019		SBC
Western Health Gold HMO C	01/01/2019		SBC
Western Health Gold HMO D (HSA Eligible)	01/01/2019		SBC
Western Health Silver HMO A	01/01/2019		SBC
Western Health Silver HMO B	01/01/2019		SBC
Western Health Silver HMO C (HSA Eligible)	01/01/2019		SBC
Western Health Bronze HMO B	01/01/2019		SBC
Western Health Bronze HMO C (HSA Eligible)	01/01/2019		SBC
Western Health Bronze HMO D (HSA Eligible) - Discontinued effective 4.19	01/01/2019		SBC
2019 Medical PPO and EPO SBCs
Anthem Blue Cross PPO and EPO
Anthem Blue Cross Gold Advantage PPO A	01/01/2019		SBC
Anthem Blue Cross Gold Advantage PPO A [Benefit Update 10.19]	10/01/2019		SBC
Anthem Blue Cross Gold Select PPO B	01/01/2019		SBC
Anthem Blue Cross Gold Select PPO B [Benefit Update 10.19]	10/01/2019		SBC
Anthem Blue Cross Gold Select PPO C	01/01/2019		SBC
Anthem Blue Cross Gold Select PPO C [Benefit Update 10.19]	10/01/2019		SBC
Anthem Blue Cross Gold Select PPO D	01/01/2019		SBC
Anthem Blue Cross Gold Select PPO D [Benefit Update 10.19]	10/01/2019		SBC
Anthem Blue Cross Silver Advantage PPO A	01/01/2019		SBC
Anthem Blue Cross Silver Advantage PPO A [Benefit Update 10.19]	10/01/2019		SBC
Anthem Blue Cross Silver Select PPO B	01/01/2019		SBC
Anthem Blue Cross Silver Select PPO B [Benefit Update 10.19]	10/01/2019		SBC
Anthem Blue Cross Silver EPO A	01/01/2019		SBC
Anthem Blue Cross Silver EPO A [Benefit Update 10.19]	10/01/2019		SBC
Anthem Blue Cross Silver EPO B (HSA Eligible)	01/01/2019		SBC
Anthem Blue Cross Bronze EPO A	01/01/2019		SBC
Anthem Blue Cross Bronze EPO A [Benefit Update 10.19]	10/01/2019		SBC
Oscar EPO
Oscar Platinum EPO A	01/01/2019		SBC
Oscar Platinum EPO B	01/01/2019		SBC
Oscar Gold EPO A	01/01/2019		SBC
Oscar Gold EPO B	01/01/2019		SBC
Oscar Gold EPO C	01/01/2019		SBC
Oscar Gold EPO D	01/01/2019		SBC
Oscar Silver EPO A (HSA Eligible)	01/01/2019		SBC
Oscar Silver EPO B	01/01/2019		SBC
Oscar Silver EPO C	01/01/2019		SBC
Oscar Bronze EPO A (HSA Eligible)	01/01/2019		SBC
Oscar Bronze EPO B	01/01/2019		SBC

Form Name	Effective Date	Download Form
General Information
CaliforniaChoice Fast Facts Brochure 1.20 to 6.20 Effective Dates	01/01/2020	Download
CaliforniaChoice Fast Facts Brochure 7.20	07/01/2020	Download
CaliforniaChoice Underwriting Guidelines 1.20 to 6.20	01/01/2020	Download
CaliforniaChoice Underwriting Guidelines 7.20	07/01/2020	Download
CaliforniaChoice Total Choice Option [new effective 12/1/2020]	12/01/2020	Download
Cal Perks Flyer	01/01/2020	Download
Employer Guide to Optional Benefits 1.20 to 3.20 Effective Dates	01/01/2020	Download
Employer Guide to Optional Benefits 4.20 to 6.20 Effective Dates	04/01/2020	Download
Employer Guide to Optional Benefits 7.20 to 9.20 Effective Dates	07/01/2020	Download
Mammoth HR Cheat Sheet Flyer	08/01/2020	Download
Mobile App Flyer 1.20	01/01/2020	Download
Payroll & HRIS Solutions via CaliforniaChoice	01/01/2020	Download
POP Flyer	01/01/2020	Download
Smart Decision Technology Overview for Brokers	01/01/2020	Download
Smart Decision Technology Overview for Employers	01/01/2020	Download
Smart Decision Technology - Automated Choice Profiler	01/01/2020	Download
Smart Decision Technology - Online Enrollment	01/01/2020	Download
Smart Decision Technology - Online Provider Search	01/01/2020	Download
Smart Decision Technology - Online Rx Search	01/01/2020	Download
Value Plus Benefits Flyer	01/01/2020	Download
Website Features Flyer	01/01/2020	Download
Schedule Of Commissions	01/01/2020	Download
Medical
Anthem Advantage PPO Tier Hospital Network	01/01/2018	Download
CaliforniaChoice HSA Guide 1.20	01/01/2020	Download
CaliforniaChoice HSA Guide 1.21	01/01/2021	Download
CaliforniaChoice Member Enrollment Guide 1.20 to 3.20 Effective Dates	01/01/2020	Download
CaliforniaChoice Member Enrollment Guide 4.20 Effective Dates	04/01/2020	Download
CaliforniaChoice Member Enrollment Guide 5.20 to 6.20 Effective Dates	05/01/2020	Download
CaliforniaChoice Renewal Plan Transition Guide 1.20 to 3.20 Effective Dates	01/01/2020	Download
CaliforniaChoice Renewal Plan Transition Guide 4.20 to 9.20 Effective Dates	04/01/2020	Download
CaliforniaChoice Renewal Plan Transition Guide1.21 Effective Dates	01/01/2021	Download
CaliforniaChoice Summary of Changes for Groups Renewing 1.20 to 3.20	01/01/2020	Download
CaliforniaChoice Summary of Changes for Groups Renewing 4.20	04/01/2020	Download
CaliforniaChoice Summary of Changes for Groups Renewing 5.20 to 6.20	05/01/2020	Download
CaliforniaChoice Summary of Changes for Groups Renewing 7.20 to 8.20	07/01/2020	Download
CaliforniaChoice Summary of Changes for Groups Renewing 10.20 to 11.20	10/01/2020	Download
CaliforniaChoice Summary of Changes for Groups Renewing 1.21	01/01/2021	Download
Infertility Benefit Grid 1.20 to 6.20 Effective Dates	01/01/2020	Download
Infertility Benefit Grid 10.20 to 12.20 Effective Dates	10/01/2020	Download
Infertility Benefit Grid 1.21 Effective Dates	01/01/2021	Download
Medicare Part D Credibility 1.20 to 6.20 Effective Dates	01/01/2020	Download
Medicare Part D Credibility 10.20 to 12.20 Effective Dates	10/01/2020	Download
Medicare Part D Credibility 1.21 Effective Dates	01/01/2021	Download
Network Availability by Carrier & Plan 7.20	07/01/2020	Download
Network Availability by Carrier & Plan 10.20	10/01/2020	Download
Online Provider Search Instructions	01/01/2020	Download
Provider Network Definitions 1.20	01/01/2020	Download
Provider Network Definitions 10.20	10/01/2020	Download
Provider Network Definitions 1.21	01/01/2021	Download
SBC-EOC Flyer	01/01/2020	Download
Ancillary
Chiropractic Benefits Flyer	01/01/2020	Download
Dental Benefits Flyer 1.20 to 6.20 Effective Dates	01/01/2020	Download
Dental Benefits Flyer 7.20	07/01/2020	Download
Hearing Value Added Benefit Flyer	01/01/2020	Download
Life Insurance Benefits Flyer 1.20	01/01/2020	Download
Vision Benefits Flyer	01/01/2020	Download

Video Name	Watch Video
Intro to CaliforniaChoice	Watch Video Intro to CaliforniaChoice
CaliforniaChoice What is Defined Contribution?	Watch Video CaliforniaChoice What is Defined Contribution?
CaliforniaChoice Health Insurance Plans	Watch Video CaliforniaChoice Health Insurance Plans
CaliforniaChoice Ease of Administration	Watch Video CaliforniaChoice Ease of Administration
CaliforniaChoice Additional Plans and Perks	Watch Video CaliforniaChoice Additional Plans and Perks
CaliforniaChoice Working with Health Insurance Brokers	Watch Video CaliforniaChoice Working with Health Insurance Brokers

Form Name	Effective Date	Download Form
Rate Guide Summary [effective 10/1/2020]	10/01/2020	Download
Rate Guide Summary [effective 1/1/2021 to 3/1/2021]	01/01/2021	Download

CaliforniaChoice

Provider Finder