Skip to Main Content

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 II (HMO) H0562 - 116
  • Alameda
Ruby Select (HMO) H0562 - 103
  • Yolo
Seniority Plus Sapphire (HMO)

H0562 - 111-001

 

  • Los Angeles, Orange & San Diego
Seniority Plus Sapphire (HMO) H0562 - 111-002
  • Kern
Seniority Plus Sapphire (HMO) H0562 - 111-003
  • Riverside & San Bernardino
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  Summary of Benefits
Amber I (HMO SNP) H0562 - 055
  • Fresno, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Francisco & Tulare
Seniority Plus Amber II (HMO SNP)  H0562 - 110-001
  • Fresno, Los Angeles, Orange, San Diego & San Francisco

 

Seniority Plus Amber II (HMO SNP)  H0562 - 110-002
  • Kern, Tulare
Seniority Plus Amber II (HMO SNP)  H0562 - 110-003
  • Riverside, San Bernardino
Seniority Plus Amber II Premier (HMO SNP)  H3561 - 001
  • Fresno
Jade (HMO SNP) H0562 - 092
  • Kern, Los Angeles & Orange
Jade (HMO SNP) H0562 - 114
  • San Diego

For HMO Members

Plan CMS# County Evidence of Coverage
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 II (HMO) H0562 - 116
  • Alameda
Ruby Select (HMO) H0562 - 103
  • Yolo
Sapphire (HMO)

H0562 - 111-001

 

  • Los Angeles, Orange & San Diego
Sapphire (HMO) H0562 - 111-002
  • Kern
Sapphire (HMO) H0562 - 111-003
  • Riverside & San Bernardino
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 SNP) H0562 - 055
  • Fresno, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Francisco & Tulare
Amber II (HMO SNP)  H0562 - 110-001
  • Fresno, Los Angeles, Orange, San Diego & San Francisco

 

Amber II (HMO SNP)  H0562 - 110-002 
  • Kern, Tulare
Amber II (HMO SNP)  H0562 - 110-003
  • Riverside, San Bernardino
Amber II Premier (HMO SNP)  H3561 - 001 
  • Fresno
Jade (HMO SNP) H0562 - 092 
  • Kern, Los Angeles & Orange
Jade (HMO 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 - 111-001
  • Los Angeles, Orange & San Diego
Sapphire (HMO) H0562 - 111-002
  • Kern
Sapphire (HMO) H0562 - 111-003
  • Riverside & San Bernardino
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

 

For HMO SNP Members

Plan CMS# County Annual Notice of Changes
Amber I (HMO SNP) H0562 - 055
  • Fresno, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Francisco & Tulare
Amber II (HMO SNP)  H0562 - 110-001
  • Fresno, Los Angeles, Orange, San Diego & San Francisco
Amber II (HMO SNP) H0562 - 110-002
  • Kern, Tulare
Amber II (HMO SNP)

H0562 - 110-003

  • Riverside, San Bernardino
Amber II Premier (HMO SNP)  H3561 - 001
  • Fresno
Jade (HMO SNP)

H0562 - 092

 

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

H0562 - 114

  • San Diego

For HMO Members

Plan CMS# County Low Income Subsidy
Gold Select (HMO) H0562 - 101-001
  • Los Angeles, Orange
Gold Select (HMO) H0562 - 101-002
  • 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
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 (HMO)

H0562 - 090
  • Santa Clara
Ruby Select (HMO) H0562 - 097
  • San Francisco
Ruby Select (HMO) H0562 - 112
  • Fresno
Ruby Select (HMO) H0562 - 113
  • Alameda
Ruby Select II (HMO) H0562 - 116
  • Alameda
Ruby Select (HMO) H0562 - 103
  • Yolo
Sapphire (HMO)

H0562 - 111-001

 

  • Los Angeles, Orange & San Diego
Sapphire (HMO) H0562 - 111-002
  • Kern
Sapphire (HMO) H0562 - 111-003
  • Riverside & San Bernardino
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

 

For HMO SNP Members

Plans CMS#    County  Low Income Subsidy
Amber I (HMO SNP) H0562 - 055
  • Fresno, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Francisco & Tulare
Amber II (HMO SNP)  H0562 - 110-001
  • Fresno, Los Angeles, Orange, San Diego & San Francisco
Amber II (HMO SNP)  H0562 - 110-002 
  • Kern, Tulare
Amber II (HMO SNP)  H0562 - 110-003
  • Riverside, San Bernardino
Amber II Premier (HMO SNP)  H3561 - 001 
  • Fresno
Jade (HMO SNP) H0562 - 092 
  • Kern, Los Angeles & Orange
Jade (HMO SNP) H0562 - 114 
  • San Diego

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

Ordering is easy! Just follow the steps listed on your plan's catalog.

 

Can't find what you need? Contact Member Services. We are here to help!