HEALTH INSURANCE


EMPLOYEE BENEFIT SUMMARY

BLUE SHIELD 80/60 PPO AND TRIO HMO PLANS

Blue Shield Group Number and Contact Information

Group Number: W0002943
Blue Shield Member Services: (800) 424-6521
Website: www.blueshieldca.com

*Blue Shield 80/60 PPO

Blue Shield 80/60 PPO Benefit Summary
Plan Year October 1, 2017 to September 30, 2018

 TRIO ACO HMO

Blue Shield TRIO ACO HMO Benefit Summary
Plan Year October 1, 2017 to September 30, 2018

Chiropractic/Acupuncture Information

Prescription Drug Mail Order Center

Group Number: 977986-0003 
Member Services: (866) 346-7200     
Website: www.myprimemail.com

Blue Shield Summary of Prescription Drug Coverage

Claim Form

Subscriber's Statement of Claim

  Employee Change Form

To add, delete, or change employee coverage, click the link below to download

*IMPORTANT NOTICE:
Forms are due to Human Resources within 30 days of the qualifying event. If the form is received on the 31st day or after; coverage is not available until open enrollment in the upcoming fiscal year.

KAISER PERMANENTE HMO PLAN

Kaiser Permanente Group Number and Contact Information 

 Group Number: 109082-0000
Kaiser Member Services: (800) 464-4000
Website: kp.org

Kaiser Summary of Benefits 

Plan Year October 1, 2017 to September 30, 2018

Chiropractic/Acupuncture Information

Employee Change Form

To add, delete, or change employee coverage, click the link below to download
Change Form
 
*IMPORTANT NOTICE:
Forms are due to Human Resources within 30 days of the qualifying event. If the form is received on the 31st day or after; coverage is not available until open enrollment in the upcoming fiscal year.

DELTA DENTAL PPO PLAN

Delta Dental PPO Group Number and Contact Information

Group Number: 07023-05205
Delta Dental Member Services: (866) 499-3001
Website: www.deltadental.com  

Plan Year: October 1, 2017 to September 30, 2018

In-Network Dentist: $0 Calendar Year Deductable/$2000 maximum benefit  
Out-of-Network Dentist: $100 Calendar Year Deductable/$1500 maximum benefit 
70/30 Coverage First Calendar Year or First Year of Utilization
80/20 Coverage if Plan is Utilized in the Previous Year
90/10 Coverage if Plan is Utilized in the Previous Year
100% Coverage if Plan is Utilized in the Previous Year and each year thereafter


Employee Change Form

To add, delete, or change employee coverage, click the link below to download
Change Form
 
*IMPORTANT NOTICE:
Forms are due to Human Resources within 30 days of the qualifying event. If the form is received on the 31st day or after; coverage is not available until open enrollment in the upcoming fiscal year.

MEDICAL EYE SERVICES (MES) VISION PLAN

Medical Eye Services (MES) Vision Plan Information

MES Group Number:  32083
MES Services: 800-877-6372
Website: www.mesvision.com

 MES Summary of Benefits
Plan Year:  October 1, 2017 to September 30, 2018

Employee Change Form

To add, delete, or change employee coverage, click the link below to download


*IMPORTANT NOTICE:
Forms are due to Human Resources within 30 days of the qualifying event. If the form is received on the 31st day or after; coverage is not available until open enrollment in the upcoming fiscal year.

BLUE SHIELD TERM LIFE AND ACCIDENTAL DEATH/DISMEMBERMENT PLAN

CONTACT US

550 Blumont St. 
Laguna Beach, CA 92651 
P:949-497-7700
F:949-497-6021
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