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Blue Shield of California
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Benefit Summary Guide
This Guide Highlights the products available from Blue Shield. It provides you with the detailed benefit information needed to make informed choices about healthcare coverage., 212 Pages (Rev. 05/10)
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Dental Claim Form
Used for submitting Dental Claims, 1 Page (Rev. 08-06)
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Drug Formulary - Member Booklet
Formulary Drug Guide, for Barnd Name & Generic Drugs, 76 Pages (Rev. 09-09)
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Employee Application for Small Groups 2-50
Includes Waiver of Coverage. , 6 Pages (Rev. 3/10)
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Employee Health Statement
Required for groups of 2-14 enrolling employees & non-GI groups only. Small groups who wish to be considered for an RAF other than standard may also submit Health Statements for consideration., 2 Pages (Rev. 3/10)
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Employer Questionnaire
Health questionnaire for group 15-50, 2 Pages (Rev. 3/10)
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Employer Request for Contract Change Form
This form should be used to expedite change requests for clients renewing group contracts.
, 3 Pages (Rev. 3/10)
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Full-Time Student Certification
Full-time student certification, To be eligible for coverage, unmarried children over the age of 18 must be enrolled full-time in college (minimum
of 12 units) or trade school. This form must be completed and signed by the employee., 1 Page (Rev. 1-09)
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Group Administration Guide
Guide for administering Blue Shield Plans, 48 Pages (Rev. 01/10)
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Group Change Transmital/Termination
Used to fax Group changes, termination or additions for Medical and Dental., 1 Page (Rev. 06/10)
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HIPPA Disclosure Authorization
Must be signed by the plan member to authorize Blue Shield to release personal & health information to a third party., 2 Pages (Rev. 8/07)
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Language Assantance Program
Used for employees to obtain free help in translating vital medical documents, 2 Pages (Rev. 01/09)
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Life Disability Addendum
1 Page (Rev. 1/04)
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Life Evidence of Insurability
2 Pages (Rev. 9/03)
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Master Group Application
Group Application for groups 2-50.
, 8 Pages (Rev. 03/10)
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Medical Claim Form
Employees should use this form ONLY when the Provider of Service does not submit their claim directly to Blue Shield. This is for Blue Shield Life plans.
, 1 Page (Rev. 03/07)
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Medical Claim Form
Employees should use this form ONLY when the Provider of Service does not submit their claim directly to Blue Shield. This is for Blue Shield of California plans.
, 1 Page (Rev. 01-07)
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New Group Submittal Check List
Employers Checklist for all required paperwork., 1 Page (Rev. 03-19-09)
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Prescription Direct Reimbursement Claim Form
Prescription Drug Reimbursement Claim Form, 2 Pages (Rev. 6/09)
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Prior Carrier Accumulation
Used to submit to Blue Shield for Credit of Prior Carriers deductable., 1 Page (Rev. 08/09)
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Refusal of Personal Coverage
Complete if you, your spouse, domectic partner or dependent(s) are refusing your employers Blue Shield health or dental coverage., 1 Page (Rev. 5/10)
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Request for Continuity of Care
Transfer of care form, 2 Pages (Rev. 1/07)
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Sole Proprietor, Partner or Corporate Officer Statement
Small Group Requirements for proof of eligibility when owners not listed on the DE6, 1 Page (Rev. 6/10)
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Statement of Domestic Partnership
Domestic partnership agreement, 1 Page (Rev. 08/06)
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Subscriber Change Request
Employee Change Request Form.
, 2 Pages (Rev. 3/10)
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Verification and Statement of Understanding
Employer verifies that noi wrap plan (as defined in this verification) will be used in conjunction with any Blue Shield Health Plan, with the exception of the Shield Spectrum PPO Savings Plan 2250/4500, now or in the future., 2 Pages (Rev. 05/09)
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Vision Claim Form
Used for submitting Vision Clames to Blue Shield, 1 Page (Rev. 3-09)
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Access Baja® HMO Plan 10
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS., 2 Pages (Rev. 07/10)
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Access Baja® HMO Plan 5
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS., 2 Pages (Rev. 07/10)
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Blue Shield Active Choice 500
A health plan designed to allow members to be active participants in their own health care. The Active Choice Plan offers coverage for preventive care services with no up-front deductible, as well as a $500 individual/$1,000 family “First Dollar Services” coverage for specified services. Each calendar year, the member can spend this First Dollar Services coverage on certain outpatient professional and diagnostic services, from an office visit for preventive care to physical therapy benefits., 6 Pages (Rev. 07/10)
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Blue Shield Active Choice 750
A health plan designed to allow members to be active participants in their own health care. The Active Choice Plan offers
coverage for preventive care services with no up-front deductible, as well as a $750 individual/$1,500 family “First Dollar
Services” coverage for specified services. Each calendar year, the member can spend this First Dollar Services coverage on
certain outpatient professional and diagnostic services, from an office visit for preventive care to physical therapy benefits., 6 Pages (Rev. 07/10)
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Shield Savings Plan 1800/3600
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE CERTIFICATE OF INSURANCE AND THE GROUP POLICY SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS., 4 Pages (Rev. 07/10)
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Shield Savings Plan 2000
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE CERTIFICATE OF INSURANCE AND THE GROUP POLICY SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS., 4 Pages (Rev. 07/10)
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Shield Savings Plan 2250/4500
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND THE PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS., 4 Pages (Rev. 07/10)
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Shield Savings Plan 2500
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE CERTIFICATE OF INSURANCE AND THE GROUP POLICY SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS., 4 Pages (Rev. 07/10)
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Shield Savings Plan 3000/6000
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE CERTIFICATE OF INSURANCE AND THE GROUP POLICY SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS., 4 Pages (Rev. 07/10)
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Shield Savings Plan 4800
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE CERTIFICATE OF INSURANCE AND THE GROUP POLICY SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS., 4 Pages (Rev. 07/10)
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Added Advantage POS ℠ Plan
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND THE PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS., 4 Pages (Rev. 07/10)
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Shield Spectrum PPO ℠ Plan, Zero Deductible
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND THE PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS., 4 Pages (Rev. 07/10)
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Shield Spectrum PPO℠ Plan 1000
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND THE PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS., 4 Pages (Rev. 07/10)
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Shield Spectrum PPO℠ Plan 1000 Value†
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE CERTIFICATE OF INSURANCE AND GROUP POLICY SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS., 4 Pages (Rev. 07/10)
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Shield Spectrum PPO℠ Plan 1500 Value†
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND THE PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS., 4 Pages (Rev. 07/10)
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Shield Spectrum PPO℠ Plan 2000 Value†
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE CERTIFICATE OF INSURANCE AND GROUP POLICY SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS., 4 Pages (Rev. 07/10)
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Shield Spectrum PPO℠ Plan 250 Premier
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND THE PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS., 4 Pages (Rev. 07/10)
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Shield Spectrum PPO℠ Plan 250 Standard
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND THE PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS., 4 Pages (Rev. 07/10)
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Shield Spectrum PPO℠ Plan 3000
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE CERTIFICATE OF INSURANCE AND GROUP POLICY SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS., 4 Pages (Rev. 07/10)
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Shield Spectrum PPO℠ Plan 500 Premier
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND THE PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS., 4 Pages (Rev. 07/10)
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Shield Spectrum PPO℠ Plan 500 Standard
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND THE PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS., 4 Pages (Rev. 07/10)
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Shield Spectrum PPO℠ Plan 500 Value
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND THE PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS., 4 Pages (Rev. 07/10)
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Shield Spectrum PPO℠ Plan 750 Value†
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE CERTIFICATE OF INSURANCE AND GROUP POLICY SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS., 4 Pages (Rev. 07/10)
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Access+ HMO® Plan 10
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND THE PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS., 3 Pages (Rev. 07/10)
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Access+ HMO® Plan 15
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND THE PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.
, 3 Pages (Rev. 07/10)
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Access+ HMO® Plan 20
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND THE PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS., 3 Pages (Rev. 07/10)
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Access+ HMO® Plan 20 Value
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND THE PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS., 3 Pages (Rev. 07/10)
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Access+ HMO® Plan 25
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND THE PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS., 3 Pages (Rev. 07/10)
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Access+ HMO® Plan 30
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND THE PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS., 3 Pages (Rev. 07/10)
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Access+ HMO® Plan 40
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND THE PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS., 3 Pages (Rev. 07/10)
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Access+ HMO® Plan 5
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND THE PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS., 3 Pages (Rev. 07/10)
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Local Access+ HMO® Plan 20 Value
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND THE PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS., 3 Pages (Rev. 07/10)
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Local Access+ HMO® Plan 30
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS ASUMMARY ONLY. THE EVIDENCE OF COVERAGE AND THE PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS., 3 Pages (Rev. 07/10)
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For additional information, please contact Claremont at 800.696.4543
or info@claremontcompanies.com
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