Active Health & Welfare – Plan Documents & Forms
Fillable PDF Forms
Some PDF forms on this site are fillable online. You can type information directly onto the PDF.
By default, Firefox does not currently support forms in fillable format. To use this feature, view the site in Chrome or Microsoft Edge.
Plan Documents & Amendments
Enrollment
Plan A Enrollment Guide
Plan A New Member Enrollment Form
Plan A Enrollment Change Form
Plan B Enrollment Guide
Plan B New Member Enrollment Form
Plan B Enrollment Change Form
Plan C Enrollment Guide
Plan C New Member Enrollment Form
Plan C Enrollment Change Form
Plan K20 Enrollment Guide
Plan K500 Enrollment Guide
Plan K1000 Enrollment Guide
Plan K New Member Enrollment Form
Plan K Enrollment Change Form
Summary of Benefits & Coverage
Active HW – Plan A
Plan A-Anthem SBC
Plan A-Kaiser SBC
Active HW – Plan B
Plan B-Anthem SBC
Plan B-Kaiser SBC
Active HW – Plan C
Plan C-Anthem SBC
Plan C-Kaiser SBC
Active HW – Plan K20
Plan K20-Kaiser SBC
Active HW – Plan K500
Plan K500-Kaiser SBC
Active HW – Plan K1000
Plan K1000-Kaiser SBC
General Forms
General Notices
Summary of Material Modifications & Plan Notices
Effective June 1, 2020 – Improvements in the MAC for Hip & Knee Surgery, June 2020 Eligibility for Class 1 Participants Only
Effective January 1, 2020 – Health Dynamics Program Exam Requirement Suspended for Plan Year 2020
Effective September 1, 2019 – Bright Now! (Newport) Dental Plan Option is Terminated
Effective April 1, 2019 Initial Dental Enrollment & Enrolling a Newborn Child
Effective January 1, 2019 – Health Dynamics Program and Deductible Changes, Plans A,B, or C including COBRA Participants
Effective January 1, 2019 – Network Change for Participants Enrolled in Plan B Indemnity Plan
CalPERS & Anthem Blue Cross Hip and Knee Joint Replacement Program
Effective January 1, 2018 – Deductible Change, Plans A, B or C including COBRA Participants
Effective September 1, 2017 – Domestic Partner Coverage – Imputed Income
Effective July 1, 2015 – LiveHealth Online Services for Direct Pay Plan Participants
LiveHealth Online Brochure
Effective January 1, 2015, Direct Pay Plans – Out of Pocket Limits on Cost Sharing, New Blue Cross Value Based Program, Dollar Limit on Non-PPO Surgical Centers, & Specialty Medications