CA Medicare Plans - Forms and Brochures

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 
Green (HMO) H0562 - 044
 
  • Los Angeles, Riverside & San Bernardino
Green (HMO)

H0562 - 045
  • Alameda, Placer, Sacramento, Sonoma & 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 (HMO)

H0562 - 095
  • Santa Clara
Ruby Select (HMO) H056 - 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

 

  • Fresno, Los Angeles, Orange, San Diego & San Francisco
Sapphire Premier (HMO) H3561 - 004
  • Riverside & 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
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, Sonoma & 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 (HMO) H0567- 095
  • Santa Clara
Ruby Select (HMO)

H056 - 097

 

  • San Francisco
Ruby Select (HMO) H0562 - 112
  • Fresno
  • English - Annual Notice of Changes
     
  • Español - Annual Notice of Changes
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

 

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

H3561 - 004

  • Riverside & San Bernardino

 

For HMO SNP Members

Plans CMS#    County  Annual Notice 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 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, Sonoma & 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 (HMO)

H0562 - 095
  • Santa Clara
Ruby Select (HMO) H056 - 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

 

  • Fresno, Los Angeles, Orange, San Diego & San Francisco
Sapphire Premier (HMO) H3561 - 004
  • 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 LIS Premium Charts
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 - 095
  • Santa Clara
Ruby Select (HMO) H056 - 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

 

  • Fresno, Los Angeles, Orange, San Diego & San Francisco
Sapphire Premier (HMO) H3561 - 004
  • Riverside & San Bernardino

 

For HMO SNP Members

Plans CMS#    County  LIS Premium Charts
Amber I (HMO SNP) H0562 - 055
  • Fresno, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Francisco & Tulare
Amber II (HMO SNP)  H0562 - 100-001
  • 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