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Title Form # Effective Date
Aetna - Dental 01-01-2019
Aetna - Medical 01-01-2019

Title Form # Effective Date
AVN HMO 1.7 04-01-2013
AVN HMO 11.7 04-01-2013
AVN HMO 12.4 04-01-2013
AVN HMO 12.7 04-01-2013
AVN HMO 16.7 04-01-2013
AVN HMO 21.7 04-01-2013
AVN HMO 22.7 04-01-2013
AVN HMO 23.7 04-01-2013
AVN HMO 4.7 04-01-2013
AVN HMO 9.7 04-01-2013
CA AVN HMO 10 01-01-2015
CA AVN HMO 10A 01-01-2015
CA AVN HMO 15 01-01-2015
CA AVN HMO 15/20 250 01-01-2015
CA AVN HMO 15/20 300 01-01-2015
CA AVN HMO 15A 01-01-2015
CA AVN HMO 20 01-01-2015
CA AVN HMO 20/25 01-01-2015
CA AVN HMO 30/40 1000 01-01-2015
CA AVN HMO 30/40 750 01-01-2015
CA AVN HMO 40/50 1000 01-01-2015
CA Basic HMO $10 04-01-2013
CA Basic HMO $30 04-01-2013
CA Basic HMO 10 01-01-2015
CA Basic HMO 10A 01-01-2015
CA Basic HMO 15 01-01-2015
CA Basic HMO 15/20 250 01-01-2015
CA Basic HMO 15/20 300 01-01-2015
CA Basic HMO 15A 01-01-2015
CA Basic HMO 20 01-01-2015
CA Basic HMO 20/25 01-01-2015
CA Basic HMO 30/40 1000 01-01-2015
CA Basic HMO 30/40 750 01-01-2015
CA Basic HMO 40/50 1000 01-01-2015
CA Basic HMO Deductible 1000 10/20 01-01-2015
CA Basic HMO Deductible 1000 15/25 01-01-2015
CA Basic HMO Deductible 1000 20/40 01-01-2015
CA Basic HMO Deductible 1000 30/50 01-01-2015
CA Basic HMO Deductible 1500 10/20 01-01-2015
CA Basic HMO Deductible 2000 40/60 01-01-2015
CA Basic HMO Deductible 250 10/25 01-01-2015
CA Basic HMO Deductible 250 15/25 01-01-2015
CA Basic HMO Deductible 500 10/15 01-01-2015
CA Basic HMO Deductible 500 10/20 01-01-2015
CA Basic HMO Deductible 500 40/50 01-01-2015
CA Basic HMO Deductible 5500 50% 01-01-2015
CA HMO 10 01-01-2015
CA HMO 10A 01-01-2015
CA HMO 15 01-01-2015
CA HMO 15/20 250 01-01-2015
CA HMO 15/20 300 01-01-2015
CA HMO 15A 01-01-2015
CA HMO 20 01-01-2015
CA HMO 20/25 01-01-2015
CA HMO 30/40 1000 01-01-2015
CA HMO 30/40 750 01-01-2015
CA HMO 40/50 1000 01-01-2015
CA HMO Deductible 1000 10/20 01-01-2015
CA HMO Deductible 1000 15/25 01-01-2015
CA HMO Deductible 1000 20/40 01-01-2015
CA HMO Deductible 1000 30/50 01-01-2015
CA HMO Deductible 1500 10/20 01-01-2015
CA HMO Deductible 2000 40/60 01-01-2015
CA HMO Deductible 250 10/25 01-01-2015
CA HMO Deductible 250 15/25 01-01-2015
CA HMO Deductible 500 10/15 01-01-2015
CA HMO Deductible 500 10/20 01-01-2015
CA HMO Deductible 500 40/50 01-01-2015
CA HMO Deductible 5500 50% 01-01-2015
CA HMO HRA 1000 01-01-2015
CA HMO HRA 500 01-01-2015
CA HMO HRA 750 01-01-2015
CA PrimeCare HMO 10A 01-01-2015
CA PrimeCare HMO 20/25 01-01-2015
CA PrimeCare HMO 40/50 1000 01-01-2015
CA PrimeCare HMO Deductible 1000 30/50 01-01-2015
CA PrimeCare HMO Deductible 500 10/20 01-01-2015
HMO 1.7 04-01-2013
HMO 10.7 04-01-2013
HMO 10.7 04-01-2013
HMO 11.7 04-01-2013
HMO 12.7 04-01-2013
HMO 15.7 04-01-2013
HMO 16.7 04-01-2013
HMO 21.7 04-01-2013
HMO 23.7 04-01-2013
HMO 4.7 04-01-2013
HMO 9.7 04-01-2013
HMO Deductible Plan 1.7 04-01-2013
HMO Deductible Plan 2.7 04-01-2013
HMO Deductible Plan 3.7 04-01-2013
HMO Deductible Plan 4.7 04-01-2013
HMO Deductible Plan 5.7 04-01-2013
HMO Deductible Plan 6.7 04-01-2013
HMO Deductible Plan 7.7 04-01-2013
HMO Deductible Plan 8.7 04-01-2013
HMO Deductible Plan 9.7 04-01-2013
HMO Fully Insured OOA Dependents 10-01-2010
Primecare HMO 1.2 04-01-2013
Primecare HMO 15.2 04-01-2013
Primecare HMO 22.2 04-01-2013
Title Form # Effective Date
CA OAMC 1000 75/50 30 01-01-2015
CA OAMC 1000 90/60 20 01-01-2015
CA OAMC 1500 80/50 15 01-01-2015
CA OAMC 250 90/60 20 01-01-2015
CA OAMC 250 90/60 20A 01-01-2015
CA OAMC 250 90/70 10 01-01-2015
CA OAMC 250 90/70 15 01-01-2015
CA OAMC 250 90/70 15 250 01-01-2015
CA OAMC 250 90/70 15A 01-01-2015
CA OAMC 250 90/70 20 01-01-2015
CA OAMC 2500 80/50 25 01-01-2015
CA OAMC 2500 80/60 HSA TIF 01-01-2015
CA OAMC 2500 90/70 HSA TIF 01-01-2015
CA OAMC 300 80/60 15 01-01-2015
CA OAMC 300 80/60 15A 01-01-2015
CA OAMC 3000 80/50 30 01-01-2015
CA OAMC 3500 70/50 35 01-01-2015
CA OAMC 3500 80/50 HSA TIF 01-01-2015
CA OAMC 4500 50/50 40 01-01-2015
CA OAMC 500 80/60 20 01-01-2015
CA OAMC 500 80/60 20 500A 01-01-2015
CA OAMC 500 80/60 20A 01-01-2015
CA OAMC 5000 100/50 15 01-01-2015
CA OAMC 6300 100/50 HSA EMB 01-01-2015
CA OAMC 750 80/50 30 01-01-2015
CA PPO 1000 90/60 20 01-01-2015
CA PPO 250 90/70 10 01-01-2015
CA PPO 500 80/60 20 01-01-2015
CA PrimeCare OAMC 1000 75/50 30 01-01-2015
CA PrimeCare OAMC 2500 80/50 25 01-01-2015
CA PrimeCare OAMC 3500 80/50 HSA TIF 01-01-2015
CA PrimeCare OAMC 750 80/50 30 01-01-2015
CA Savings Plus 1000 75/50 30 01-01-2015
CA Savings Plus 1000 90/60 20 01-01-2015
CA Savings Plus 1500 80/50 15 01-01-2015
CA Savings Plus 250 90/60 20 01-01-2015
CA Savings Plus 250 90/60 20A 01-01-2015
CA Savings Plus 250 90/70 10 01-01-2015
CA Savings Plus 250 90/70 15 01-01-2015
CA Savings Plus 250 90/70 15 250 01-01-2015
CA Savings Plus 250 90/70 15A 01-01-2015
CA Savings Plus 250 90/70 20 01-01-2015
CA Savings Plus 2500 80/50 25 01-01-2015
CA Savings Plus 2500 80/60 HSA TIF 01-01-2015
CA Savings Plus 2500 90/70 HSA TIF 01-01-2015
CA Savings Plus 300 80/60 15 01-01-2015
CA Savings Plus 300 80/60 15A 01-01-2015
CA Savings Plus 3000 80/50 30 01-01-2015
CA Savings Plus 3500 70/50 35 01-01-2015
CA Savings Plus 3500 80/50 HSA TIF 01-01-2015
CA Savings Plus 4500 50/50 40 01-01-2015
CA Savings Plus 500 80/60 20 01-01-2015
CA Savings Plus 500 80/60 20 500A 01-01-2015
CA Savings Plus 500 80/60 20A 01-01-2015
CA Savings Plus 5000 100/50 15 01-01-2015
CA Savings Plus 6300 100/50 HSA EMB 01-01-2015
CA Savings Plus 750 80/50 30 01-01-2015
Indemnity - Effective 4/1/2013 04-01-2013
OA MC 1.8 04-01-2013
OA MC 10.8 04-01-2013
OA MC 11.8 04-01-2013
OA MC 13.8 04-01-2013
OA MC 15.8 04-01-2013
OA MC 20.8 04-01-2013
OA MC 22.8 04-01-2013
OA MC 3.8 04-01-2013
OA MC 4.8 04-01-2013
OA MC 5.8 04-01-2013
OA MC 6.8 04-01-2013
OA MC 7.8 04-01-2013
OA MC 9.8 04-01-2013
OC PPO 13.3 04-01-2013
OC PPO 3.3 04-01-2013
Primecare OA MC 10.2 04-01-2013
Primecare OA MC 15.2 04-01-2013
Primecare OA MC 16.2 04-01-2013
Primecare OA MC 3.2 04-01-2013
Primecare OA MC 5.2 04-01-2013
Title Form # Effective Date
OA MC HSA 2.7 04-01-2013
OA MC HSA 3.7 04-01-2013
Title Form # Effective Date
CA SCCIPA EPO 1000 80 01-01-2015
CA SCCIPA EPO 2000 70 01-01-2015
CA SCCIPA EPO 250 90 01-01-2015
CA SCCIPA EPO 3500 50 01-01-2015
CA SCCIPA EPO HSA 3000 70 TIF 01-01-2015
Title Form # Effective Date
CA Indemnity 500 80% 01-01-2015
Title Form # Effective Date
2014 Producer Compensation Plans 01-01-2014
Title Form # Effective Date
Aetna Discount Programs 00.02.333.1 F 08-01-2013
Electronic Enrollment, Billing/Payment and Access Agreement
Mobile App Flyer 00.03.282. 08-01-2011
Retail Flu Vaccine 20.03.916. 07-01-2012
Retail Flu Vaccine (Espanol) 20.03.916. 08-01-2012

Title Form # Effective Date
Enrollment / Change Request FOC/DMO GR-67751 05-01-2000
Title Form # Effective Date
Dental Plan Riders 12-01-2009
Waiver Form GR-68025-C 07-01-2011