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Plan Materials and Forms

Listed below are some documents that may be helpful at different times during your membership.  

For HMO Members

Plan CMS# County Summary of Benefits
Gold Select (HMO) H0562 - 101-001
  • Los Angeles & Orange
Gold Select (HMO) H0562 - 101-002
  • Riverside & San Bernardino 
Seniority Plus Green (HMO) H0562 - 044
 
  • Los Angeles, Riverside & San Bernardino
Seniority Plus Green (HMO)

H0562 - 045
  • Alameda, Placer, Sacramento & Stanislaus
Healthy Heart (HMO) H0562 - 068
  • Alameda & Stanislaus
Healthy Heart (HMO) H0562 - 090
  • Fresno
Healthy Heart (HMO) H0562 - 100-001
  • Los Angeles & Orange
Healthy Heart (HMO) H0562 - 100-002
  • Riverside & San Bernardino
Healthy Heart (HMO) H0562 - 012
  • San Diego
Healthy Heart (HMO) H0562 - 009
  • San Francisco
Healthy Heart (HMO) H0562 - 039
  • Yolo
Healthy Heart (HMO) H0562 - 084
  • Placer & Sacramento
Seniority Plus Ruby (HMO) H0562 - 079
  • Kern 
Ruby Select (HMO) H0562 - 097
  • San Francisco
Ruby Select (HMO) H0562 - 112
  • Fresno
Ruby Select (HMO) H0562 - 113
  • Alameda
Ruby Select (HMO) H0562 - 103
  • Yolo
Healthy Heart (HMO) H0562 - 119
  • Imperial
Healthy Heart (HMO) H0562 - 120
  • Santa Clara & Stanislaus
Seniority Plus Sapphire (HMO)

H0562 - 122

 

  • Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Santa Clara & Stanislaus
Seniority Plus Sapphire Premier (HMO)

H3561 - 002

 

  • Alameda, Fresno, Kern, Los Angeles, Orange, San Diego, San Francisco & Tulare
Seniority Plus Sapphire Premier (HMO) H3561 - 004
  • Imperial, Riverside & San Bernardino
Seniority Plus Sapphire Premier II (HMO) H3561 - 005
  • Alameda, Fresno, Kern, Los Angeles, Orange, San Diego, San Francisco & Tulare
Seniority Plus Sapphire Premier II (HMO) H3561 - 006
  • Imperial, Riverside & San Bernardino

 

For HMO SNP Members

Plans CMS#    County  Summary of Benefits
Seniority Plus Amber I (HMO D-SNP) H0562 - 055
  • Fresno, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Francisco & Tulare
Jade (HMO C-SNP)  H0562 - 117
  • San Francisco

 

Jade (HMO C-SNP)  H0562 - 118
  • Fresno
Seniority Plus Amber II (HMO D-SNP)  H0562 - 121
  • Fresno, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Francisco and Tulane
Seniority Plus Amber II Premier (HMO D-SNP)  H3561 - 001
  • Fresno
Jade (HMO C-SNP) H0562 - 092
  • Kern, Los Angeles & Orange
Jade (HMO C-SNP) H0562 - 114
  • San Diego

For HMO Members

Plan CMS# County Evidence of Coverage
Gold Select (HMO) H0562 - 101-001
  • Los Angeles, Orange, Riverside & San Bernardino
Gold Select (HMO) H0562 - 101-002
  • Los Angeles, Orange, Riverside & San Bernardino 
Green (HMO) H0562 - 044

 

  • Los Angeles, Riverside & San Bernardino
Green (HMO)

H0562 - 045
  • Alameda, Placer, Sacramento & Stanislaus
Healthy Heart (HMO) H0562 - 068
  • Alameda & Stanislaus
Healthy Heart (HMO) H0562 - 090
  • Fresno
Healthy Heart (HMO) H0562 - 100-001
  • Los Angeles, Orange, Riverside & San Bernardino
Healthy Heart (HMO) H0562 - 100-002
  • Los Angeles, Orange, Riverside & San Bernardino
Healthy Heart (HMO) H0562 - 012
  • San Diego
Healthy Heart (HMO) H0562 - 009
  • San Francisco
Healthy Heart (HMO) H0562 - 039
  • Yolo
Healthy Heart (HMO) H0562 - 084
  • Placer, Sacramento
Ruby (HMO) H0562 - 079
  • Kern 
Ruby Select (HMO) H0562 - 097
  • San Francisco
Ruby Select (HMO) H0562 - 112
  • Fresno
Ruby Select (HMO) H0562 - 113
  • Alameda
Ruby Select (HMO) H0562 - 103
  • Yolo
Healthy Heart (HMO)

H0562 - 119

 

  • Imperial
Healthy Heart (HMO) H0562 - 120
  • Santa Clara and Stanislaus
Seniority Plus Sapphire (HMO) H0562 - 122
  • Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Santa Clara and Stanislaus
Sapphire Premier (HMO)

H3561 - 002

 

  • Alameda, Fresno, Kern, Los Angeles, Orange, San Diego, San Francisco & Tulare
Sapphire Premier (HMO) H3561 - 004
  • Imperial, Riverside & San Bernardino
Seniority Plus Sapphire Premier 2 (HMO)

H3561 - 005
  • Alameda, Fresno, Kern, Los Angeles, Orange, San Diego, San Francisco, Tulare
Seniority Plus Sapphire Premier II (HMO)

H3561 - 006
  • Imperial, Riverside & San Bernardino

 

For HMO SNP Members

Plans CMS#    County  Evidence of Coverage
Amber I (HMO D-SNP) H0562 - 055
  • Fresno, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Francisco & Tulare
Jade (HMO C-SNP)  H0562 - 117
  • San Francisco

 

Jade (HMO C-SNP)  H0562 - 118 
  • Fresno
Seniority Plus Amber II (HMO D-SNP)  H0562 - 121
  • Fresno, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Francisco & Tulane
Amber II Premier (HMO D-SNP)  H3561 - 001 
  • Fresno
Jade (HMO C-SNP) H0562 - 092 
  • Kern, Los Angeles & Orange
Jade (HMO C-SNP) H0562 - 114 
  • San Diego



For HMO Members

Plan CMS# County Annual Notice of Changes
Gold Select (HMO) H0562 - 101-001
  • Los Angeles, Orange
Gold Select (HMO) H0562 - 101-002
  • Riverside, San Bernardino 
Green (HMO)

H0562 - 044

 


  • Los Angeles, Riverside & San Bernardino
Green (HMO)

H0562 - 045

  • Alameda, Placer, Sacramento & Stanislaus
Healthy Heart (HMO)

H0562 - 068

 

  • Alameda & Stanislaus
Healthy Heart (HMO) H0562 - 090
  • Fresno
Healthy Heart (HMO)
H0562 - 100-001
  • Los Angeles, Orange
Healthy Heart (HMO) H0562 - 100-002
  • Riverside & San Bernardino
Healthy Heart (HMO) H0562 - 012
  • San Diego
Healthy Heart (HMO) H0562 - 009
  • San Francisco
Healthy Heart (HMO) H0562 - 039
  • Yolo
Healthy Heart (HMO) H0562 - 084
  • Placer, Sacramento
Ruby (HMO)

H0562 - 079

 

  • Kern 
Ruby Select (HMO)

H0562 - 097

 

  • San Francisco
Ruby Select (HMO) H0562 - 112
  • Fresno
Ruby Select (HMO) H0562 - 113
  • Alameda
Ruby Select (HMO)

H0562 - 103

  • Yolo
Sapphire (HMO) H0562 - 121
  • Fresno, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Francisco & Tulare.
Sapphire Premier (HMO)

H3561 - 002

 

  • Alameda, Fresno, Kern, Los Angeles, Orange, San Diego, San Francisco & Tulare
Sapphire Premier (HMO)

H3561 - 004

  • Imperial, Riverside & San Bernardino
Sapphire Premier II (HMO)

H3561 - 005

  • Alameda, Fresno, Kern, Los Angeles, Orange, San Diego, San Francisco & Tulare
Sapphire Premier II (HMO)

H3561 - 006

  • Imperial, Riverside & San Bernardino

 

For HMO SNP Members

Plan CMS# County Annual Notice of Changes
Seniority Plus Amber I (HMO D-SNP) H0562 - 055
  • Fresno, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego & San Francisco and Tulare.
Seniority Plus Amber II (HMO D-SNP)  H0562 - 121
  • Fresno, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego & San Francisco and Tulare.
Seniority Plus Amber II Premier (HMO D-SNP)  H3561 - 001
  • Fresno
Jade (HMO C-SNP)

H0562 - 092

 

  • Kern, Los Angeles & Orange
Jade (HMO C-SNP)

H0562 - 114

  • San Diego

For HMO Members

Plan CMS# County Low Income Subsidy
Gold Select (HMO) H0562 - 101-001
  • Los Angeles, Orange, Riverside & San Bernardino
Gold Select (HMO) H0562 - 101-002
  • Los Angeles, Orange, Riverside, San Bernardino 
Healthy Heart (HMO) H0562 - 068
  • Alameda & Stanislaus
Healthy Heart (HMO) H0562 - 090
  • Fresno
Healthy Heart (HMO) H0562 - 100-001
  • Los Angeles, Orange, Riverside & San Bernardino
Healthy Heart (HMO) H0562 - 100-002
  • Los Angeles, Orange, Riverside & San Bernardino
Healthy Heart (HMO) H0562 - 012
  • San Diego
Healthy Heart (HMO) H0562 - 009
  • San Francisco
Healthy Heart (HMO) H0562 - 039
  • Yolo
Healthy Heart (HMO) H0562 - 084
  • Placer, Sacramento
Seniority Plus Ruby (HMO) H0562 - 079
  • Kern 
Ruby Select (HMO) H0562 - 097
  • San Francisco
Ruby Select (HMO) H0562 - 112
  • Fresno
Ruby Select (HMO) H0562 - 113
  • Alameda
Ruby Select (HMO) H0562 - 103
  • Yolo
Healthy Heart (HMO) H0562 - 119
  • Imperial
Healthy Heart (HMO) H0562 - 120
  • Santa Clara and Stanislaus
Seniority Plus Sapphire (HMO)

H0562 - 122

 

  • Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Santa Clara and Stanislaus
Seniority Plus Sapphire Premier (HMO)

H3561 - 002

 

  • Alameda, Fresno, Kern, Los Angeles, Orange, San Diego,San Francisco & Tulare
Seniority Plus Sapphire Premier (HMO) H3561 - 004
  • Imperial, Riverside & San Bernardino
Seniority Plus Sapphire Premier II (HMO) H3561 - 005
  • Alameda, Fresno, Kern, Los Angeles, Orange, San Diego, San Francisco and Tulare
Seniority Plus Sapphire Premier II (HMO) H3561 - 006
  • Imperial, Riverside, and San Bernardino

 

For HMO SNP Members

Plans CMS#    County  Low Income Subsidy
Seniority Plus Amber I (HMO D-SNP) H0562 - 055
  • Fresno, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Francisco & Tulare
Jade (HMO C-SNP)  H0562 - 117
  • San Francisco

 

Jade (HMO C-SNP)  H0562 - 118
  • Fresno
Seniority Plus Amber II (HMO D-SNP)  H0562 - 121
  • Fresno, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Francisco and Tulane
Seniority Plus Amber II Premier (HMO D-SNP)  H3561 - 001
  • Fresno
Jade (HMO C-SNP) H0562 - 092
  • Kern, Los Angeles & Orange
Jade (HMO C-SNP) H0562 - 114
  • San Diego

Your current plan may have an over-the-counter (OTC) benefit that lets you buy OTC health and wellness products. This catalog includes a list of OTC items that you can order to be mailed to your home. Check the catalog for item limits.

Ordering is easy. Just follow the steps in your plan's catalog.

For HMO Members

Plan CMS# County Extra Benefits Brochure
Gold Select (HMO) H0562 - 101-001
  • Los Angeles, Orange, Riverside & San Bernardino
Gold Select (HMO) H0562 - 101-002
  • Los Angeles, Orange, Riverside, San Bernardino 
Seniority Plus Green (HMO) H0562 - 044
 
  • Los Angeles, Riverside & San Bernardino
Seniority Plus Green (HMO)

H0562 - 045
  • Alameda, Placer, Sacramento & Stanislaus
Healthy Heart (HMO) H0562 - 068
  • Alameda & Stanislaus
Healthy Heart (HMO) H0562 - 090
  • Fresno
Healthy Heart (HMO) H0562 - 100-001
  • Los Angeles, Orange, Riverside & San Bernardino
Healthy Heart (HMO) H0562 - 100-002
  • Los Angeles, Orange, Riverside & San Bernardino
Healthy Heart (HMO) H0562 - 012
  • San Diego
Healthy Heart (HMO) H0562 - 009
  • San Francisco
Healthy Heart (HMO) H0562 - 039
  • Yolo
Healthy Heart (HMO) H0562 - 084
  • Placer, Sacramento
Seniority Plus Ruby (HMO) H0562 - 079
  • Kern 
Ruby Select (HMO) H0562 - 097
  • San Francisco
Ruby Select (HMO) H0562 - 112
  • Fresno
Ruby Select (HMO) H0562 - 113
  • Alameda
Ruby Select (HMO) H0562 - 103
  • Yolo
Healthy Heart (HMO) H0562 - 119
  • Imperial
Healthy Heart (HMO) H0562 - 120
  • Santa Clara and Stanislaus
Seniority Plus Sapphire (HMO)

H0562 - 122

 

  • Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Santa Clara and Stanislaus
Seniority Plus Sapphire Premier (HMO)

H3561 - 002

 

  • Alameda, Fresno, Kern, Los Angeles, Orange, San Diego,San Francisco & Tulare
Seniority Plus Sapphire Premier (HMO) H3561 - 004
  • Imperial, Riverside & San Bernardino
Seniority Plus Sapphire Premier II (HMO) H3561 - 005
  • Alameda, Fresno, Kern, Los Angeles, Orange, San Diego, San Francisco and Tulare
Seniority Plus Sapphire Premier II (HMO) H3561 - 006
  • Imperial, Riverside, and San Bernardino

 

For HMO SNP Members

Plans CMS#    County  Extra Benefits Brochure
Seniority Plus Amber I (HMO D-SNP) H0562 - 055
  • Fresno, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Francisco & Tulare
Jade (HMO C-SNP)  H0562 - 117
  • San Francisco

 

Jade (HMO C-SNP)  H0562 - 118
  • Fresno
Seniority Plus Amber II (HMO D-SNP)  H0562 - 121
  • Fresno, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Francisco and Tulane
Seniority Plus Amber II Premier (HMO D-SNP)  H3561 - 001
  • Fresno
Jade (HMO C-SNP) H0562 - 092
  • Kern, Los Angeles & Orange
Jade (HMO C-SNP) H0562 - 114
  • San Diego

 

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