Plan Information & Benefit Materials

SignatureValue HMO

• Schedule of Benefits Booklet
• Schedule of Benefit Coverage
• Combined Evidence of Coverage and Disclosure Form

SignatureValue Harmony HMO

• Schedule of Benefits Booklet
• Schedule of Benefit Coverage
• Combined Evidence of Coverage and Disclosure Form

SelectPlus (PPO)

• Group Policy
• Summary of Benefits Coverage
• Certificate of Coverage
• Summary of Benefits
• Summary of Benefits - Prescription
• Summary of Benefits - Infertility

Additional documents

• Disable Dependent Child Certification Form
• 2022 County of Los Angeles ID Card Update

SignatureValue HMO

• Schedule of Benefits Booklet
• Schedule of Benefit Coverage

SignatureValue Harmony HMO

• Schedule of Benefits Booklet
• Schedule of Benefit Coverage

SelectPlus (PPO)

• Schedule of Benefits - Medical
• Schedule of Benefits - Prescription
• Schedule of Benefits - Infertility
• Schedule of Benefit Coverage

SignatureValue HMO

• Schedule of Benefits Booklet
• Schedule of Benefits
• Combined Evidence of Coverage and Disclosure Form

SignatureValue Harmony HMO

• Schedule of Benefits Booklet
• Schedule of Benefits
• Combined Evidence of Coverage and Disclosure Form

SelectPlus (PPO)

• Schedule of Benefits - Medical

Forms

• Appeals & Grievance Form
• Disabled Dependent Form

SignatureValue HMO

• Schedule of Benefits Booklet
• Schedule of Benefits
• Combined Evidence of Coverage and Disclosure Form

SignatureValue Harmony HMO

• Schedule of Benefits Booklet
• Schedule of Benefits
• Combined Evidence of Coverage and Disclosure Form

SelectPlus (PPO)

• Schedule of Benefits - Medical
• Summary of Benefits and Coverage

Forms

• Appeals & Grievance Form
• Disabled Dependent Form

SignatureValue HMO

• Schedule of Benefits Booklet
• Summary of Benefits and Coverage (SBC)
• Combined Evidence of Coverage and Disclosure Form

SelectPlus (PPO)

• Summary of Benefits and Coverage (SBC)
• Benefit Summary
• Certificate of Coverage
• Group Policy

Schedule of Benefits

• Prescription Drug Coverage
• Vision Care Coverage
• Infertility Coverage

Forms

• Appeals & Grievance Form
• Disabled Dependent Form

SignatureValue HMO

• Schedule of Benefits Booklet
• Summary of Benefits and Coverage (SBC)
• Combined Evidence of Coverage and Disclosure Form

SelectPlus (PPO)

• Summary of Benefits and Coverage (SBC)
• Benefit Summary
• Certificate of Coverage
• Group Policy

Schedule of Benefits

• Prescription Drug Coverage
• Vision Care Coverage
• Infertility Coverage

Forms

• Appeals & Grievance Form
• Disabled Dependent Form