Member Forms & Resources

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We have provided free forms and resources to help answer any questions you may have. You may download and save this documentation to your computer or device for future reference.

• ANOC - Important Information
  • 2020
    • English
      • AllCare Preferred Plan (HMO) 011
      • CalPlus (HMO) 009
      • Heart & Diabetes (HMO SNP) 010
      • My Choice (HMO) 001 - LA,OC, Riv & SB
      • My Choice (HMO) 006 - Stanislaus & San Joaquin
      • My Choice (HMO) 007 - Santa Clara
      • Platinum (HMO) 008 - Los Angeles & Orange
      • Platinum (HMO) 015 - San Bernardino & Riverside
      • Platinum (HMO) 016 - San Diego
      • smartHMO 013
    • Spanish
      • AllCare Preferred Plan (HMO) 011
      • CalPlus (HMO) 009
      • Heart & Diabetes (HMO SNP) 010
      • My Choice (HMO) 001 - LA,OC, Riv & SB
      • My Choice (HMO) 006 - Stanislaus & San Joaquin
      • My Choice (HMO) 007 - Santa Clara
      • Platinum (HMO) 008 - Los Angeles & Orange
      • Platinum (HMO) 015 - San Bernardino & Riverside
      • Platinum (HMO) 016 - San Diego
      • smartHMO 013

• Appointment of a Representative

  English

  Spanish

• Best Available Evidence

  Best Available Evidence

• CMS Fraud Awareness Tools

  Identity Theft Prevention Tips

  Consejos para la prevención del robo de identidad

  Protecting Medicare for Future Generations

  Protegiendo Medicare para futuras generaciones

• Dental Benefit Information
  • 2020
    • Dental Benefits
    • Dental Benefits - Spanish

• Drug Formulary
  • 2020
    • Drug Formulary - All Plans - English, Spanish and Chinese

  *PDFs Last Updated February 1, 2020

  Click here to request a printed Drug Formulary

• Enrollment Forms
  • 2020
    • English
      • Enrollment Application - All Other HMO Plans
      • Enrollment Application - Sutter HMO
      • Enrollment Application - Heart & Diabetes Plan
      • Enrollment Application - PPO Plan
      • Pre Qualification Form - Heart & Diabetes Plan
    • Spanish
      • Enrollment Application - All Other HMO Plans
      • Enrollment Application - Heart & Diabetes Plan
      • Enrollment Application - Sutter HMO
      • Pre-Qualification Form - Heart & Diabetes Plan
    • Chinese
      • Enrollment Application - Sutter HMO

• Evidence of Coverage
  • 2020
    • English
      • AllCare Preferred Plan (HMO) 011
      • CalPlus (HMO) 009
      • Heart & Diabetes (HMO SNP) 010
      • My Choice (HMO) 001 - LA,OC, Riv & SB
      • My Choice (HMO) 006 - Stanislaus & San Joaquin
      • My Choice (HMO) 007 - Santa Clara
      • Platinum (HMO) 008 - Los Angeles & Orange
      • Platinum (HMO) 015 - San Bernardino & Riverside
      • Platinum (HMO) 016 - San Diego
      • Platinum (HMO) 018 - Marin
      • Platinum (HMO) 025 - San Joaquin
      • smartHMO 013
      • Sutter Advantage (HMO) 019 - Sacramento, Placer & Yolo
      • Sutter Advantage (HMO) 020 - Santa Clara
      • Sutter Advantage (HMO) 021 - Santa Cruz
      • Sutter Advantage (HMO) 022 - San Mateo
      • Sutter Advantage (HMO) 023 - Sonoma
      • Sutter Advantage (HMO) 024 - San Francisco
      • My Choice (PPO) 001 - Sacramento, Placer & Yolo
      • My Choice (PPO) 002 - San Mateo
      • My Choice (PPO) 003 - Sonoma
      • My Choice (PPO) 004 - San Joaquin & Stanislaus
    • Spanish
      • AllCare Preferred Plan (HMO) 011
      • CalPlus (HMO) 009
      • Heart & Diabetes (HMO SNP) 010
      • My Choice (HMO) 001 - LA,OC, Riv & SB
      • My Choice (HMO) 006 - Stanislaus & San Joaquin
      • My Choice (HMO) 007 - Santa Clara
      • Platinum (HMO) 008 - Los Angeles & Orange
      • Platinum (HMO) 015 - San Bernardino & Riverside
      • Platinum (HMO) 016 - San Diego
      • Platinum (HMO) 018 - Marin
      • Platinum (HMO) 025 - San Joaquin
      • smartHMO 013
      • Sutter Advantage (HMO) 019 - Sacramento, Placer & Yolo
      • Sutter Advantage (HMO) 020 - Santa Clara
      • Sutter Advantage (HMO) 021 - Santa Cruz
      • Sutter Advantage (HMO) 022 - San Mateo
      • Sutter Advantage (HMO) 023 - Sonoma
      • Sutter Advantage (HMO) 024 - San Francisco
      • My Choice (PPO) 001 - Sacramento, Placer & Yolo
      • My Choice (PPO) 002 - San Mateo
      • My Choice (PPO) 003 - Sonoma
      • My Choice (PPO) 004 - San Joaquin & Stanislaus
    • 中文 (Chinese)
      • My Choice (HMO) 007- 聖塔克拉拉縣
      • Sutter Advantage (HMO) 024 - 舊金山縣

  Click here to request a printed Evidence of Coverage booklet

• Grievance & Appeals Form

  English

  Spanish

• Grocery Benefit Catalog
  • 2020
    • English
      • Grocery Catalog
    • Spanish
      • Grocery Catalog

• Healthy Rewards Catalog
  • 2020
    • English
    • Spanish

• Low Income Subsidy (LIS) Levels
  • 2020
    • English
    • Spanish

• Multi-language Interpreter Services

  Multi-language

• Notices
  • English
    • Non-Discrimination Notice
    • How to Get Care During a Disaster
  • Spanish
    • Aviso de No Discriminación
    • Cómo Obtener Atención Médica Durante un Desastre

• Over-the-Counter Brochure
  • 2020
    • English
      • Cal Plus Plan
      • Other Plans
    • Spanish
      • Cal Plus Plan
      • Otros Planes

• Pharmacy Directory
  • 2020
    • Pharmacy Directory - All Other Plans - English, Spanish and Chinese
    • Pharmacy Directory - CalPlus (HMO) - English and Spanish

  *PDFs Last Updated February 1, 2020

  Click here to request a printed Pharmacy Directory

• Plan Star Ratings
  • 2020
    • English
      • Alignment Health Plan (HMO)
      • Alignment Health Plan (PPO)
    • Spanish
      • Alignment Health Plan (HMO)
      • Alignment Health Plan (PPO)
    • Chinese
      • Alignment Health Plan (HMO)

• Pre-Enrollment Kits
  • 2020
    • English
      • AllCare Preferred Plan (HMO) - Stanislaus
      • CalPlus (HMO) - All Counties
      • Heart & Diabetes (HMO SNP) - Los Angeles & Orange
      • My Choice (HMO), Platinum (HMO) - LA, OC, Riv, SB
      • My Choice (HMO), Platinum (HMO) - San Joaquin & Stanislaus
      • My Choice (HMO), Platinum (HMO) - Santa Clara & Marin
      • My Choice (PPO) - Placer, Sacramento, San Joaquin, San Mateo, Sonoma, Stanislaus, Yolo
      • Platinum (HMO) - San Diego
      • Platinum (HMO), smartHMO - Los Angeles & Orange
      • Sutter Advantage (HMO) - Placer, Sacramento, San Francisco, San Mateo, Santa Clara, Santa Cruz, Sonoma, Yolo
    • Spanish
      • AllCare Preferred Plan (HMO) - Stanislaus
      • CalPlus (HMO) - Todos Los Condados
      • Heart & Diabetes (HMO SNP) - Los Angeles & Orange
      • My Choice (HMO), Platinum (HMO) - LA, OC, Riv, SB
      • My Choice (HMO), Platinum (HMO) - San Joaquin & Stanislaus
      • My Choice (HMO), Platinum (HMO) - Santa Clara & Marin
      • My Choice (PPO) - Placer, Sacramento, San Joaquin, San Mateo, Sonoma, Stanislaus, Yolo
      • Platinum (HMO) - San Diego
      • Platinum (HMO), smartHMO - Los Angeles & Orange
      • Sutter Advantage (HMO) - Placer, Sacramento, Sonoma, Yolo
    • Chinese
      • Sutter Advantage (HMO) - Placer, Sacramento, San Francisco, San Mateo, Santa Clara, Santa Cruz, Sonoma, Yolo

• Prior Authorization Criteria

  English

  Spanish

• Provider Directory

  For an up-to-date, real time online provider search, please click here

  Download PDF* for selected coverage area:

  • 2020
    • AllCare Preferred (HMO) - Stanislaus - English and Spanish
    • Los Angeles - English and Spanish
    • Marin - English & Spanish
    • Orange - English and Spanish
    • Riverside & San Bernardino - English and Spanish
    • San Diego - English and Spanish
    • San Joaquin, Stanislaus & Santa Clara - English and Spanish
    • Sutter Advantage (HMO) - English, Spanish and Chinese
    • My Choice (PPO) - English and Spanish

  *PDFs Last Updated February 1, 2020

  Click here to request a printed Provider Directory

• Special Enrollment Period

  SEP Attestation Form - English

  SEP Attestation Form - Spanish (Español)

• Step Therapy Protocol

  English

  Spanish

• Summary of Benefits
  • 2020
    • English
      • AllCare Preferred Plan (HMO) 011
      • CalPlus (HMO) 009
      • Heart & Diabetes (HMO SNP) 010
      • My Choice (HMO) 001, Platinum (HMO) 015 - LA,OC, Riv & SB
      • My Choice (HMO) 006, Platinum (HMO) 025 - Stanislaus & San Joaquin
      • My Choice (HMO) 007, Platinum (HMO) 018 - Santa Clara & Marin
      • Platinum (HMO) 008, smartHMO 013 - Los Angeles & Orange
      • Platinum (HMO) 016 - San Diego
      • Sutter Advantage (HMO) 019, 023 - Placer, Sacramento, Sonoma, Yolo
      • Sutter Advantage (HMO) 020, 021 - Santa Clara & Santa Cruz
      • Sutter Advantage (HMO) 022, 024 - San Francisco & San Mateo
      • My Choice (PPO) 001, 003 - Placer, Sacramento, Sonoma, Yolo
      • My Choice (PPO) 002, 004 - San Joaquin, San Mateo, Stanislaus
    • Spanish
      • AllCare Preferred Plan (HMO) 011
      • CalPlus (HMO) 009
      • Heart & Diabetes (HMO SNP) 010
      • My Choice (HMO) 001, Platinum (HMO) 015 - LA,OC, Riv & SB
      • My Choice (HMO) 006, Platinum (HMO) 025 - Stanislaus & San Joaquin
      • My Choice (HMO) 007, Platinum (HMO) 018 - Santa Clara & Marin
      • Platinum (HMO) 008, smartHMO 013 - Los Angeles & Orange
      • Platinum (HMO) 016 - San Diego
      • Sutter Advantage (HMO) 019, 023 - Placer, Sacramento, Sonoma, Yolo
      • Sutter Advantage (HMO) 020, 021 - Santa Clara & Santa Cruz
      • Sutter Advantage (HMO) 022, 024 - San Francisco & San Mateo
      • My Choice (PPO) 002, 004 - San Joaquin, San Mateo, Stanislaus
      • My Choice (PPO) 001, 003 - Placer, Sacramento, Sonoma, Yolo
    • Chinese
      • Sutter Advantage (HMO) 022, 024 - San Francisco & San Mateo