CaliforniaChoice

Form Name	Effective Date	Download Form
New Group Submission
CalChoice Submission Checklist	01/01/2018	Download
Employer Application 10.18 to 11.18 Effective Dates	10/01/2018	Download
Employer Application 12.18 Effective Dates	12/01/2018	Download
ACH Payment Form 4.18 and Later Effective Dates	04/01/2018	Download
Owner Partner Statement Form	01/01/2018	Download
Case Submission Acknowledgement (for groups submitted after the requested effective date)	01/01/2018	Download
Common Ownership Statement	01/01/2018	Download
Group Size Attestation	01/01/2018	Download
Self Funding Declaration	01/01/2018	Download
Prior Carrier Cancellation Letter Template	01/01/2018	Download
In Force Group Forms
Changes to Group Policy Guidelines	01/01/2018	Download
Employee Termination Notification 4.18 and Later Effective Dates	04/01/2018	Download
Employer Change Request Form 10.18 - 11.18 Effective Dates	10/01/2018	Download
Employer Change Request Form 12.18 Effective Dates	12/01/2018	Download
Employer Group Contact Change	01/01/2018	Download
Employer In Force Group Dental Application 4.18 and later effective dates	04/01/2018	Download
Employer Inforce Group Voluntary Vision Application 10.17 and later effective dates	01/01/2018	Download
Employer Recertification Agreement	01/01/2018	Download
Exception Request Form	01/01/2018	Download
Group COBRA Billing Contract	01/01/2018	Download
Administration
Employer Administrative Guide 7.18	07/01/2018	Download
Employer Administrative Guide 12.18	12/01/2018	Download
Employer Program Guide 1.18 to 3.18 Effective Dates	01/01/2018	Download
Employer Program Guide 4.18 to 6.18 Effective Dates	04/01/2018	Download
Employer Program Guide 7.18 to 9.18 Effective Dates	07/01/2018	Download
Employer Program Guide 10.18 to 11.18 Effective Dates	10/01/2018	Download
Employer Program Guide 12.18 Effective Dates	12/01/2018	Download

Form Name	Effective Date	Download Form
Enrollment and Change Forms
Employee Application 10.18 to 11.18 Effective Dates	10/01/2018	Download
Employee Application 12.18 Effective Dates	12/01/2018	Download
Employee Change Request Form 10.18 to 11.18 Effective Dates	10/01/2018	Download
Employee Change Request Form 12.18 Effective Dates	12/01/2018	Download
Domestic Partner Affidavit Form	10/01/2018	Download
Claim Forms
RX Claim Form - Aetna		Download
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 - Aetna		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
2018 Medical Plan Summary Booklets
Q1
All Tiers Benefit Summaries 1/1/18 - 3/1/18 Effective Dates	01/01/2018	Summary
Platinum Benefit Summaries 1/1/18 - 3/1/18 Effective Dates	01/01/2018	Summary
Platinum/Gold Benefit Summaries 1/1/18 - 3/1/18 Effective Dates	01/01/2018	Summary
Gold Benefit Summaries 1/1/18 - 3/1/18 Effective Dates	01/01/2018	Summary
Gold/Silver Benefit Summaries 1/1/18 - 3/1/18 Effective Dates	01/01/2018	Summary
Silver Benefit Summaries 1/1/18 - 3/1/18 Effective Dates	01/01/2018	Summary
Silver/Bronze Benefit Summaries 1/1/18 - 3/1/18 Effective Dates	01/01/2018	Summary
Bronze Benefit Summaries 1/1/18 - 3/1/18 Effective Dates	01/01/2018	Summary
Q2
All Tiers Benefit Summaries 4/1/18 - 6/1/18 Effective Dates	04/01/2018	Summary
Platinum Benefit Summaries 4/1/18 - 6/1/18 Effective Dates	04/01/2018	Summary
Platinum/Gold Benefit Summaries 4/1/18 - 6/1/18 Effective Dates	04/01/2018	Summary
Gold Benefit Summaries 4/1/18 - 6/1/18 Effective Dates	04/01/2018	Summary
Gold/Silver Benefit Summaries 4/1/18 - 6/1/18 Effective Dates	04/01/2018	Summary
Silver Benefit Summaries 4/1/18 - 6/1/18 Effective Dates	04/01/2018	Summary
Silver/Bronze Benefit Summaries 4/1/18 - 6/1/18 Effective Dates	04/01/2018	Summary
Bronze Benefit Summaries 4/1/18 - 6/1/18 Effective Dates	04/01/2018	Summary
Q3
All Tiers Benefit Summaries 7/1/18 - 9/1/18 Effective Dates	07/01/2018	Summary
Platinum Benefit Summaries 7/1/18 - 9/1/18 Effective Dates	07/01/2018	Summary
Platinum/Gold Benefit Summaries 7/1/18 - 9/1/18 Effective Dates	07/01/2018	Summary
Gold Benefit Summaries 7/1/18 - 9/1/18 Effective Dates	07/01/2018	Summary
Gold/Silver Benefit Summaries 7/1/18 - 9/1/18 Effective Dates	07/01/2018	Summary
Silver Benefit Summaries 7/1/18 - 9/1/18 Effective Dates	07/01/2018	Summary
Silver/Bronze Benefit Summaries 7/1/18 - 9/1/18 Effective Dates	07/01/2018	Summary
Bronze Benefit Summaries 7/1/18 - 9/1/18 Effective Dates	07/01/2018	Summary
Q4
All Tiers Benefit Summaries 10/1/18 - 11/1/18 Effective Dates	10/01/2018	Summary
All Tiers Benefit Summaries 12/1/18 Effective Dates	12/01/2018	Summary
Platinum Benefit Summaries 10/1/18 - 11/1/18 Effective Dates	10/01/2018	Summary
Platinum/Gold Benefit Summaries 10/1/18 - 11/1/18 Effective Dates	10/01/2018	Summary
Gold Benefit Summaries 10/1/18 - 11/1/18 Effective Dates	10/01/2018	Summary
Gold/Silver Benefit Summaries 10/1/18 - 11/1/18 Effective Dates	10/01/2018	Summary
Silver Benefit Summaries 10/1/18 - 11/1/18 Effective Dates	10/01/2018	Summary
Silver/Bronze Benefit Summaries 10/1/18 - 11/1/18 Effective Dates	10/01/2018	Summary
Bronze Benefit Summaries 10/1/18 - 11/1/18 Effective Dates	10/01/2018	Summary
2018 Medical HMO and HSP SBCs
Anthem HMO
Anthem Blue Cross Select A Platinum HMO	01/01/2018		SBC
Anthem Blue Cross Select A Gold HMO	01/01/2018		SBC
Anthem Blue Cross Select A Silver HMO	01/01/2018		SBC
Health Net HMO and HSP
Health Net Salud A Platinum HMO (Discontinued 10.1.18)	01/01/2018		SBC
Health Net WholeCare B Platinum HMO (Discontinued 10.1.18)	01/01/2018		SBC
Health Net WholeCare C Platinum HMO (10.1.18 and Later Effective Dates)	10/01/2018		SBC
Health Net Salud D Platinum HMO (10.1.18 and Later Effective Dates)	10/01/2018		SBC
Health Net SmartCare E Platinum HMO (10.1.18 and Later Effective Dates)	10/01/2018		SBC
Health Net WholeCare A Gold HMO	01/01/2018		SBC
Health Net WholeCare B Gold HMO	01/01/2018		SBC
Health Net WholeCare C Gold HMO (10.1.18 and Later Effective Dates)	10/01/2018		SBC
Health Net Salud D Gold HMO (10.1.18 and Later Effective Dates)	10/01/2018		SBC
Health Net SmartCare E Gold HMO (10.1.18 and Later Effective Dates)	10/01/2018		SBC
Health Net WholeCare A Silver HMO	01/01/2018		SBC
Health Net CommunityCare B Silver HMO	01/01/2018		SBC
Health Net PureCare A Gold HSP (Discontinued 10.1.18)	01/01/2018		SBC
Health Net PureCare A Silver HSP	01/01/2018		SBC
Health Net PureCare A Bronze HSP	01/01/2018		SBC
Kaiser Permanente HMO
Kaiser A Platinum HMO	01/01/2018		SBC
Kaiser B Platinum HMO	01/01/2018		SBC
Kaiser A Gold HMO	01/01/2018		SBC
Kaiser B Gold HMO	01/01/2018		SBC
Kaiser B Silver HMO	01/01/2018		SBC
Kaiser C Silver HMO	01/01/2018		SBC
Kaiser D Silver HMO (HSA Eligible)	01/01/2018		SBC
Kaiser A Bronze HMO	01/01/2018		SBC
Kaiser C Bronze HMO (HSA Eligible)	01/01/2018		SBC
Sharp HMO
Sharp Premier A Platinum HMO	01/01/2018		SBC
Sharp Performance B Platinum HMO	01/01/2018		SBC
Sharp Premier C Platinum HMO	01/01/2018		SBC
Sharp Performance A Gold HMO	01/01/2018		SBC
Sharp Premier B Gold HMO	01/01/2018		SBC
Sharp Premier C Gold HMO (Discontinued 7.1.18)	01/01/2018		SBC
Sharp Performance D Gold HMO (7.1.18 and Later Effective Dates)	07/01/2018		SBC
Sharp Premier A Silver HMO	01/01/2018		SBC
Sharp Performance B Silver HMO	01/01/2018		SBC
Sharp Premier C Silver HMO	01/01/2018		SBC
Sharp Premier A Bronze HMO	01/01/2018		SBC
Sharp Performance B Bronze HMO (HSA Eligible)	01/01/2018		SBC
Sharp Premier D Bronze HMO (HSA Eligible)	01/01/2018		SBC
Sutter Health Plus HMO
Sutter Health Plus A Platinum HMO	01/01/2018		SBC
Sutter Health Plus B Platinum HMO	01/01/2018		SBC
Sutter Health Plus A Gold HMO	01/01/2018		SBC
Sutter Health Plus B Gold HMO	01/01/2018		SBC
Sutter Health Plus B Silver HMO	01/01/2018		SBC
Sutter Health Plus C Silver HMO (HSA Eligible)	01/01/2018		SBC
Sutter Health Plus A Bronze HMO	01/01/2018		SBC
Sutter Health Plus B Bronze HMO (HSA Eligible)	01/01/2018		SBC
UnitedHealthcare HMO
UHC SignatureValue A Platinum HMO	01/01/2018		SBC
UHC Focus B Platinum HMO	01/01/2018		SBC
UHC Alliance C Platinum HMO	01/01/2018		SBC
UHC SignatureValue A Gold HMO	01/01/2018		SBC
UHC Alliance B Gold HMO	01/01/2018		SBC
UHC Focus C Gold HMO	01/01/2018		SBC
UHC SignatureValue A Silver HMO	01/01/2018		SBC
UHC Alliance B Silver HMO	01/01/2018		SBC
UHC Alliance C Silver HMO	01/01/2018		SBC
UHC Focus D Silver HMO	01/01/2018		SBC
UHC Alliance B Bronze HMO (HSA Eligible)	01/01/2018		SBC
UHC Alliance C Bronze HMO	01/01/2018		SBC
Western Health Advantage HMO
Western Health A Platinum HMO	01/01/2018		SBC
Western Health B Platinum HMO	01/01/2018		SBC
Western Health A Gold HMO	01/01/2018		SBC
Western Health B Gold HMO	01/01/2018		SBC
Western Health C Gold HMO	01/01/2018		SBC
Western Health D Gold HMO (HSA Eligible)	01/01/2018		SBC
Western Health A Silver HMO	01/01/2018		SBC
Western Health B Silver HMO	01/01/2018		SBC
Western Health C Silver HMO (HSA Eligible)	01/01/2018		SBC
Western Health B Bronze HMO	01/01/2018		SBC
Western Health C Bronze HMO (HSA Eligible)	01/01/2018		SBC
Western Health D Bronze HMO (HSA Eligible)	01/01/2018		SBC
2018 Medical PPO and EPO SBCs
Anthem Blue Cross PPO and EPO
Anthem Blue Cross Advantage A Gold PPO	01/01/2018		SBC
Anthem Blue Cross Select B Gold PPO	01/01/2018		SBC
Anthem Blue Cross Select C Gold PPO	01/01/2018		SBC
Anthem Blue Cross Select D Gold PPO	01/01/2018		SBC
Anthem Blue Cross Advantage A Silver PPO	01/01/2018		SBC
Anthem Blue Cross Select B Silver PPO	01/01/2018		SBC
Anthem Blue Cross A Silver EPO	01/01/2018		SBC
Anthem Blue Cross B Silver EPO (HSA Eligible)	01/01/2018		SBC
Anthem Blue Cross A Bronze EPO	01/01/2018		SBC
Oscar EPO (released for 12.1.18 in rating areas 15,16 and 18)
Oscar Platinum EPO A (available for 12/1/18 effective dates)	12/01/2018		SBC
Oscar Platinum EPO B (available for 12/1/18 effective dates)	12/01/2018		SBC
Oscar Gold EPO A (available for 12/1/18 effective dates)	12/01/2018		SBC
Oscar Gold EPO B (available for 12/1/18 effective dates)	12/01/2018		SBC
Oscar Gold EPO C (available for 12/1/18 effective dates)	12/01/2018		SBC
Oscar Silver EPO A (available for 12/1/18 effective dates)	12/01/2018		SBC
Oscar Silver EPO B (available for 12/1/18 effective dates)	12/01/2018		SBC
Oscar Bronze EPO A (available for 12/1/18 effective dates)	12/01/2018		SBC
Oscar Bronze EPO B (available for 12/1/18 effective dates)	12/01/2018		SBC
2017 Medical Plan Summary Booklets
All Tiers Benefit Summaries	10/01/2017	Summary
Platinum Benefit Summaries	10/01/2017	Summary
Platinum/Gold Benefit Summaries	10/01/2017	Summary
Gold Benefit Summaries	10/01/2017	Summary
Gold/Silver Benefit Summaries	10/01/2017	Summary
Silver Benefit Summaries	10/01/2017	Summary
Silver/Bronze Benefit Summaries	10/01/2017	Summary
Bronze Benefit Summaries	10/01/2017	Summary
2017 Medical HMO and HSP SBCs
Anthem HMO
Anthem Blue Cross Select A Platinum HMO	10/01/2017		SBC
Anthem Blue Cross Select A Gold HMO	10/01/2017		SBC
Anthem Blue Cross Select A Silver HMO	10/01/2017		SBC
Health Net HMO and HSP
Health Net Salud A Platinum HMO	10/01/2017		SBC
Health Net WholeCare A Gold HMO	10/01/2017		SBC
Health Net WholeCare B Gold HMO	10/01/2017		SBC
Health Net PureCare A Gold HSP	10/01/2017		SBC
Health Net PureCare A Silver HSP	10/01/2017		SBC
Health Net PureCare A Bronze HSP	10/01/2017		SBC
Kaiser Permanente HMO
Kaiser A Platinum HMO	10/01/2017		SBC
Kaiser A Gold HMO	10/01/2017		SBC
Kaiser B Gold HMO	10/01/2017		SBC
Kaiser B Silver HMO	10/01/2017		SBC
Kaiser C Silver HMO	10/01/2017		SBC
Kaiser D Silver HMO (HSA Eligible)	10/01/2017		SBC
Kaiser B Bronze HMO	10/01/2017		SBC
Kaiser C Bronze HMO (HSA Eligible)	10/01/2017		SBC
Sharp HMO
Sharp Premier A Platinum HMO	10/01/2017		SBC
Sharp Performance B Platinum HMO	10/01/2017		SBC
Sharp Premier C Platinum HMO	10/01/2017		SBC
Sharp Performance A Gold HMO	10/01/2017		SBC
Sharp Premier B Gold HMO	10/01/2017		SBC
Sharp Premier C Gold HMO	10/01/2017		SBC
Sharp Premier A Silver HMO	10/01/2017		SBC
Sharp Performance B Silver HMO	10/01/2017		SBC
Sharp Premier C Silver HMO	10/01/2017		SBC
Sharp Premier A Bronze HMO	10/01/2017		SBC
Sharp Performance B Bronze HMO (HSA Eligible)	10/01/2017		SBC
Sharp Premier D Bronze HMO (HSA Eligible)	10/01/2017		SBC
Sutter Health Plus HMO
Sutter Health Plus A Platinum HMO	10/01/2017		SBC
Sutter Health Plus B Platinum HMO	10/01/2017		SBC
Sutter Health Plus A Gold HMO	10/01/2017		SBC
Sutter Health Plus B Gold HMO	10/01/2017		SBC
Sutter Health Plus B Silver HMO	10/01/2017		SBC
Sutter Health Plus C Silver HMO (HSA Eligible)	10/01/2017		SBC
Sutter Health Plus A Bronze HMO	10/01/2017		SBC
Sutter Health Plus B Bronze HMO (HSA Eligible)	10/01/2017		SBC
UnitedHealthcare HMO
UHC SignatureValue A Platinum HMO	10/01/2017		SBC
UHC Focus B Platinum HMO	10/01/2017		SBC
UHC Alliance C Platinum HMO	10/01/2017		SBC
UHC SignatureValue A Gold HMO	10/01/2017		SBC
UHC Alliance B Gold HMO	10/01/2017		SBC
UHC Focus C Gold HMO	10/01/2017		SBC
UHC SignatureValue A Silver HMO	10/01/2017		SBC
UHC Alliance B Silver HMO	10/01/2017		SBC
UHC Alliance C Silver HMO	10/01/2017		SBC
UHC Focus D Silver HMO	10/01/2017		SBC
UHC Alliance B Bronze HMO (HSA Eligible)	10/01/2017		SBC
UHC Alliance C Bronze HMO	10/01/2017		SBC
Western Health Advantage HMO
Western Health A Platinum HMO	10/01/2017		SBC
Western Health B Platinum HMO	10/01/2017		SBC
Western Health A Gold HMO	10/01/2017		SBC
Western Health B Gold HMO	10/01/2017		SBC
Western Health C Gold HMO	10/01/2017		SBC
Western Health D Gold HMO (HSA Eligible)	10/01/2017		SBC
Western Health A Silver HMO	10/01/2017		SBC
Western Health B Silver HMO	10/01/2017		SBC
Western Health C Silver HMO (HSA Eligible)	10/01/2017		SBC
Western Health B Bronze HMO	10/01/2017		SBC
Western Health C Bronze HMO (HSA Eligible)	10/01/2017		SBC
Western Health D Bronze HMO (HSA Eligible)	10/01/2017		SBC
2017 Medical PPO and EPO SBCs
Anthem Blue Cross Advantage A Gold PPO	10/01/2017		SBC
Anthem Blue Cross Select B Gold PPO	10/01/2017		SBC
Anthem Blue Cross Select C Gold PPO	10/01/2017		SBC
Anthem Blue Cross Select D Gold PPO	10/01/2017		SBC
Anthem Blue Cross Advantage A Silver PPO	10/01/2017		SBC
Anthem Blue Cross Select B Silver PPO	10/01/2017		SBC
Anthem Blue Cross A Silver EPO	10/01/2017		SBC
Anthem Blue Cross B Silver EPO (HSA Eligible)	10/01/2017		SBC
Anthem Blue Cross A Bronze EPO	10/01/2017		SBC
Anthem Blue Cross B Bronze EPO (HSA Eligible)	10/01/2017		SBC

Form Name	Effective Date	Download Form
Anthem Advantage PPO Tier Hospital Network	01/01/2018	Download
CalChoice Program Highlights Effective 1/1/18	01/01/2018	Download
CalChoice Program Highlights Effective 12/1/18	12/01/2018	Download
CalChoice vs Wrap Comparison Flyer	01/01/2018	Download
CalChoice 2018 Deductible and Out-of-Pocket Max Credit Reference Sheet	01/01/2018	Download
Cal Perks Flyer	01/01/2018	Download
Infertility Services Chart 1.18 to 6.18 Effective Dates	01/01/2018	Download
Infertility Services Chart 7.18 to 9.18 Effective Dates	07/01/2018	Download
Infertility Services Chart 10.18 to 12.18 Effective Dates	10/01/2018	Download
Member Enrollment Guide 1.18 to 3.18 Effective Dates	01/01/2018	Download
Member Enrollment Guide 4.18 to 6.18 Effective Dates	04/01/2018	Download
Member Enrollment Guide 7.18 to 9.18 Effective Dates	07/01/2018	Download
Member Value Program Flyer	01/01/2018	Download
Network Availability by Carrier & Plan Summary 1.18 to 6.18 Effective Dates	01/01/2018	Download
Network Availability by Carrier & Plan Summary 7.18 to 9.18 Effective Dates	07/01/2018	Download
Network Availability by Carrier & Plan Summary 10.18 to 12.18 Effective Dates	10/01/2018	Download
Provider Network Definitions 1.18 to 6.18 Effective Dates	01/01/2018	Download
Provider Network Definitions 7.18 to 9.18 Effective Dates	07/01/2018	Download
Provider Network Definitions 10.18 to 12.18 Effective Dates	10/01/2018	Download
Provider Search Instructions	04/01/2018	Download
Renewal Plan Transition Guide 7.18 to 9.18 Effective Dates	07/01/2018	Download
Renewal Plan Transition Guide 10.18 to 12.18 Effective Dates	10/01/2018	Download
Schedule Of Commissions	01/01/2018	Download
Summary of Changes for Groups Renewing 7.18 to 9.18	07/01/2018	Download
Summary of Changes for Groups Renewing 10.18 to 11.18	10/01/2018	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
Carrier Contacts		Download

CaliforniaChoice

Provider Finder