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Blue Shield of California 51-299
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BS 51+ Application Employer
11 Pages (Rev. 8-2011)
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BS 51+ Employee Application
Must be completed by each enrolling employee., 6 Pages (Rev. 8/2011)
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BS 51+ Employee Change Transmittal Form
Submit a monthly summary of employee changes., 2 Pages (Rev. 8/2011)
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BS 51+ Employer Questionnaire
For Groups 51- 299. Submit with Master Group Application, 1 Page (Rev. 9/04)
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BS 51+ Group Administrative Guide
64 Pages (Rev. 6/2011)
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BS Disability Addendum
Provides carrier & subscriber name for DI employees. Submit with the Group Application., 1 Page (Rev. 1/04)
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BS Employee Cancellation Transmittal Request Form
Submit a monthly summary of employee terminations., 2 Pages (Rev. 8/2011)
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BS 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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BS Refusal of Personal Coverage
This form should be completed and submitted when eligible employees are refusing the employer's Blue Shield of California/Blue Shield of California Life & Health Insurance Company health plan coverage for themselves and/or their spouse, domestic partner, or dependent(s) if applicable., 2 Pages (Rev. 8/2011)
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COBRA Group Continuation Form (HMO)
For HMO COBRA enrollees, 1 Page (Rev. 2/04)
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COBRAServ Waiver
For groups choosing to not use Ceridian COBRA Services for COBRA administration., 1 Page (Rev. 5/07)
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Group Continuation Coverage (COBRA) Election Form
If you are self administering or have a third party federal COBRA administrator and you have a qualified beneficiary electing to participate in COBRA, they must complete this application., 1 Page (Rev. 8/08)
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Statement of Domestic Partnership
1 Page (Rev. 8/06)
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Shield Spectrum PPO 0/500 100/50
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY.
, 3 Pages (Rev. 1/2012)
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Shield Spectrum PPO 0/500-90/70 Premier
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY.
, 3 Pages (Rev. 1/2012)
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Shield Spectrum PPO 0/500-90/70 Standard
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY.
, 3 Pages (Rev. 1/2012)
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Shield Spectrum PPO 0/500-90/70 Standard Foundation
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY.
, 3 Pages (Rev. 1/2012)
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Shield Spectrum PPO 1000-80/50
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY.
, 3 Pages (Rev. 1/2012)
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Shield Spectrum PPO 1000-80/60 Premier
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY.
, 3 Pages (Rev. 1/2012)
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Shield Spectrum PPO 1000-90/70
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY.
, 3 Pages (Rev. 1/2012)
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Shield Spectrum PPO 250 - 90/70 Value
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY.
, 3 Pages (Rev. 1/2012)
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Shield Spectrum PPO 250 - 90/70 Value Foundation
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY.
, 3 Pages (Rev. 1/2012)
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Shield Spectrum PPO 250-80/60 Standard
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY.
, 3 Pages (Rev. 1/2012)
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Shield Spectrum PPO 250-90/70 Premier
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY.
, 3 Pages (Rev. 1/2012)
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Shield Spectrum PPO 250-90/70 Standard
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY.
, 3 Pages (Rev. 1/2012)
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Shield Spectrum PPO 3000-80/60
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY.
, 3 Pages (Rev. 1/2012)
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Shield Spectrum PPO 500-80/60
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY.
, 3 Pages (Rev. 1/2012)
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Shield Spectrum PPO 500-80/60 Foundation
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY.
, 3 Pages (Rev. 1/2012)
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Shield Spectrum PPO 500-90/70
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY.
, 3 Pages (Rev. 1/2012)
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Core Flex 1000
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY., 3 Pages (Rev. 1/2012)
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Core Flex 2200
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY., 3 Pages (Rev. 1/2012)
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Core Flex Basic Value
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY.
, 3 Pages (Rev. 1/2012)
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Active Choice 750 Foundation
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY.
, 5 Pages (Rev. 1/2012)
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Active Choice Plan 500
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY.
, 5 Pages (Rev. 1/2012)
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Active Choice Plan 500 1500 Deductible
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY.
, 5 Pages (Rev. 1/2012)
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Active Choice Plan 750
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY.
, 5 Pages (Rev. 1/2012)
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Active Choice Plan 750 1000 Deductible
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY.
, 5 Pages (Rev. 1/2012)
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Active Choice Plan 750 70/50
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY.
, 5 Pages (Rev. 1/2012)
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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.
, 2 Pages (Rev. 1/2012)
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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.
, 2 Pages (Rev. 1/2012)
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Access+ HMO 10-0 Inpatient
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY.
, 2 Pages (Rev. 1/2012)
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Access+ HMO 10-100/Day Inpatient
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY.
, 2 Pages (Rev. 1/2012)
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Access+ HMO 10-20%/Zero Facility Deductible
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY.
, 2 Pages (Rev. 1/2012)
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Access+ HMO 10-200/Day Inpatient
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY.
, 2 Pages (Rev. 1/2012)
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Access+ HMO 10-250/Admit Inpatient
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY.
, 2 Pages (Rev. 1/2012)
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Access+ HMO 15-10%/1500 Facility Deductible
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY.
, 2 Pages (Rev. 1/2012)
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Access+ HMO 15-20%/Zero Facility Deductible
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY.
, 2 Pages (Rev. 1/2012)
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Access+ HMO 15-500/Admit Inpatient
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY.
, 2 Pages (Rev. 1/2012)
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Access+ HMO 15-500/Day Inpatient
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY.
, 2 Pages (Rev. 1/2012)
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Access+ HMO 20-25%/Zero Facility Deductible
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY.
, 2 Pages (Rev. 1/2012)
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Access+ HMO 20-250/Admit Inpatient
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY.
, 2 Pages (Rev. 1/2012)
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Access+ HMO 20-500/Admit Inpatient
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY.
, 2 Pages (Rev. 1/2012)
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Access+ HMO 25-500/Admit Inpatient
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY.
, 2 Pages (Rev. 1/2012)
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Access+ HMO 25-750/Day Inpatient
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY.
, 2 Pages (Rev. 1/2012)
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Access+ HMO 30-10%/1500 Facility Deductible
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY.
, 2 Pages (Rev. 1/2012)
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Access+ HMO 30-20%/Zero Facility Deductible
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY.
, 2 Pages (Rev. 1/2012)
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Access+ HMO 40-1000/Day Inpatient
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY.
, 2 Pages (Rev. 1/2012)
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Access+ HMO 40-40%/Zero Facility Deductible
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY.
, 2 Pages (Rev. 1/2012)
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Access+ HMO 45-50%/Zero Facility Deductible
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY.
, 2 Pages (Rev. 1/2012)
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Access+ HMO 5-0 Inpatient
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY.
, 2 Pages (Rev. 1/2012)
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For additional information, please contact Claremont at 800.696.4543
or info@claremontcompanies.com
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