Active Health & Welfare – Plan Documents & Forms
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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 March 18, 2020 – Plan Changes for COVID-19
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