Summary of Benefits 2025
For 2025 medical plans, the Summary of Benefits (SOBs) include coverage information in a simplified format, making it easier for members to read and understand their plan benefits. SOBs are included in renewals, open enrollment materials and member welcome kits as part of the Evidence of Coverage (EOC).
When providing a SOB to an applicant or Blue Shield member, you must also include a disclosure and a Notice of Language Assistance (PDF, 1.1 MB).
In addition to the SOBs, the Summary of Benefits and Coverage (SBC) Forms provide your clients with an easy-to-understand overview of what our plans for groups of 1 to 100 cover. Click here to download SBC forms and other resources.
These SOBs are effective January 1, 2025, for small businesses of 1 to 100.
Off-exchange package for Small Business – HMO plans
| Blue Shield Off-Exchange HMO Plans | Summary of Benefits | Disclosures | Optional Benefit |
|---|---|---|---|
| Platinum Access+ HMO® 0/20 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997 KB) Spanish (PDF, 863 KB) |
| Platinum Local Access+ HMO® 0/20 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997 KB) Spanish (PDF, 863 KB) |
| Platinum Trio HMO 0/20 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997 KB) Spanish (PDF, 863 KB) |
| Platinum Access+ HMO® 0/25 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997 KB) Spanish (PDF, 863 KB) |
| Platinum Local Access+ HMO® 0/25 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997 KB) Spanish (PDF, 863 KB) |
| Platinum Trio HMO 0/25 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997 KB) Spanish (PDF, 863 KB) |
| Platinum Access+ HMO® 0/30 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997 KB) Spanish (PDF, 863 KB) |
| Platinum Local Access+ HMO® 0/30 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997 KB) Spanish (PDF, 863 KB) |
| Platinum Trio HMO 0/30 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997 KB) Spanish (PDF, 863 KB) |
| Gold Access+ HMO® 0/35 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997 KB) Spanish (PDF, 863 KB) |
| Gold Local Access+ HMO® 0/35 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997 KB) Spanish (PDF, 863 KB) |
| Gold Trio HMO 0/35 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997 KB) Spanish (PDF, 863 KB) |
| Gold Access+ HMO® 500/35 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997 KB) Spanish (PDF, 863 KB) |
| Gold Local Access+ HMO® 500/35 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997 KB) Spanish (PDF, 863 KB) |
| Gold Trio HMO 500/35 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997 KB) Spanish (PDF, 863 KB) |
| Gold Access+ HMO® 1000/35 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997 KB) Spanish (PDF, 863 KB) |
| Gold Local Access+ HMO® 1000/35 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997 KB) Spanish (PDF, 863 KB) |
| Gold Trio HMO 1000/35 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997 KB) Spanish (PDF, 863 KB) |
| Gold Access+ HMO® 1500/35 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 97 KB) Spanish (PDF, 863 KB) |
| Gold Local Access+ HMO® 1500/35 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997 KB) Spanish (PDF, 863 KB) |
| Gold Trio HMO 1500/35 OffEx | English (PDF, 49 KB) Spanish (PDF, 49 KB) |
English (PDF, 1.1 MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997 KB) Spanish (PDF, 863 KB) |
| Silver Access+ HMO® 2300/70 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997 KB) Spanish (PDF, 863 KB) |
| Silver Access+ HMO® 2750/70 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997 KB) Spanish (PDF, 863 KB) |
| Silver Local Access+ HMO® 2300/70 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997 KB) Spanish (PDF, 863 KB) |
| Silver Local Access+ HMO® 2750/70 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997 KB) Spanish (PDF, 863 KB) |
| Silver Trio HMO 2300/70 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997 KB) Spanish (PDF, 863 KB) |
| Silver Trio HMO 2750/70 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997 KB) Spanish (PDF, 863 KB) |
| Bronze Access+ HMO® 7000/70 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997 KB) Spanish (PDF, 863 KB) |
| Bronze Local Access+ HMO 7000/70 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997 KB) Spanish (PDF, 863 KB) |
| Bronze Trio HMO 7000/70 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997 KB) Spanish (PDF, 863 KB) |
Mirror package for Small Business – HMO plans
| Blue Shield Mirror HMO Plans | Summary of Benefits | Disclosures | Optional Benefit |
|---|---|---|---|
| Blue Shield Trio Platinum 90 HMO 0/20 PCP + Child Dental | English (PDF, 1MB) Spanish (PDF, 1.8MB) |
English (PDF, 1.1MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 1.0MB) Spanish (PDF, 863 KB) |
| Blue Shield Trio Gold 80 HMO 250/35 PCP + Child Dental | English (PDF, 1MB) Spanish (PDF, 1.8MB) |
English (PDF, 1.1MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 1.0MB) Spanish (PDF, 863 KB) |
| Blue Shield Trio Silver 70 HMO 2500/55 PCP + Child Dental | English (PDF, 1MB) Spanish (PDF, 1.8MB) |
English (PDF, 1.1MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 1.0MB) Spanish (PDF, 863 KB) |
| Blue Shield Access+ Gold 80 HMO® 250/35 PCP + Child Dental | English (PDF, 227KB) Spanish (PDF, 276KB) |
English (PDF, 311KB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 1.0MB) Spanish (PDF, 863 KB) |
| Blue Shield Access+ Platinum 90 HMO® 0/20 PCP + Child Dental | English (PDF, 218KB) Spanish (PDF, 263KB) |
English (PDF, 311KB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 1.0MB) Spanish (PDF, 863 KB) |
| Blue Shield Access+ Silver 70 HMO® 2500/55 PCP + Child Dental | English (PDF, 220KB) Spanish (PDF, 267KB) |
English (PDF, 311KB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 1.0MB) Spanish (PDF, 863 KB) |
| Blue Shield Trio Bronze 60 HMO® 7000/70 PCP + Child Dental Alt | English (PDF, 231KB) Spanish (PDF, 271KB) |
English (PDF, 311KB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 1.0MB) Spanish (PDF, 863 KB) |
Off-exchange package for Small Business – PPO plans
| Blue Shield Off-Exchange PPO Plans | Summary of Benefits | Disclosures | Optional Benefit |
|---|---|---|---|
| Platinum Full PPO 0/0 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.8MB) |
English (PDF, 1.1MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997KB) Spanish (PDF, 863 KB) |
| Platinum Tandem PPO 0/0 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.8MB) |
English (PDF, 1.1MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997KB) Spanish (PDF, 863 KB) |
| Platinum Full PPO 0/10 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.8MB) |
English (PDF, 1.1MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997KB) Spanish (PDF, 863 KB) |
| Platinum Tandem PPO 0/10 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.8MB) |
English (PDF, 1.1MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997KB) Spanish (PDF, 863 KB) |
| Platinum Full PPO 250/10 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.8MB) |
English (PDF, 1.1MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997KB) Spanish (PDF, 863 KB) |
| Platinum Tandem PPO 250/10 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.8MB) |
English (PDF, 1.1MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997KB) Spanish (PDF, 863 KB) |
| Platinum Full PPO 250/15 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.8MB) |
English (PDF, 1.1MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997KB) Spanish (PDF, 863 KB) |
| Platinum Tandem PPO 250/15 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.9MB) |
English (PDF, 1.1MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997KB) Spanish (PDF, 863 KB) |
| Gold Full PPO 0/35 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.8MB) |
English (PDF, 1.1MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997KB) Spanish (PDF, 863 KB) |
| Gold Tandem PPO 0/35 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.8MB) |
English (PDF, 1.1MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997KB) Spanish (PDF, 863 KB) |
| Gold Full PPO 500/30 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.8MB) |
English (PDF, 1.1MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997KB) Spanish (PDF, 863 KB) |
| Gold Tandem PPO 500/30 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.9MB) |
English (PDF, 1.1MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997KB) Spanish (PDF, 863 KB) |
| Gold Full PPO 750/30 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.8MB) |
English (PDF, 1.1MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997KB) Spanish (PDF, 863 KB) |
| Gold Tandem PPO 750/30 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.9MB) |
English (PDF, 1.1MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997KB) Spanish (PDF, 863 KB) |
| Gold Full PPO 1000/30 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.8MB) |
English (PDF, 1.1MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997KB) Spanish (PDF, 863 KB) |
| Gold Tandem PPO 1000/30 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.9MB) |
English (PDF, 1.1MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997KB) Spanish (PDF, 863 KB) |
| Silver Full PPO 1700/60 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.8MB) |
English (PDF, 1.1MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997KB) Spanish (PDF, 863 KB) |
| Silver Tandem PPO 1700/60 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.9MB) |
English (PDF, 1.1MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997KB) Spanish (PDF, 863 KB) |
| Silver Full PPO 2100/65 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.8MB) |
English (PDF, 1.1MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997KB) Spanish (PDF, 863 KB) |
| Silver Tandem PPO 2100/65 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.9MB) |
English (PDF, 1.1MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997KB) Spanish (PDF, 863 KB) |
| Silver Full PPO 2350/70 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.8MB) |
English (PDF, 1.1MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997KB) Spanish (PDF, 863 KB) |
| Silver Tandem PPO 2350/70 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.9MB) |
English (PDF, 1.1MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997KB) Spanish (PDF, 863 KB) |
| Bronze Full PPO 4500/65 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.9MB) |
English (PDF, 1.1MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997KB) Spanish (PDF, 863 KB) |
| Bronze Tandem PPO 4500/65 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.9MB) |
English (PDF, 1.1MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997KB) Spanish (PDF, 863 KB) |
| Bronze Full PPO 6250/65 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.9MB) |
English (PDF, 1.1MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997KB) Spanish (PDF, 863 KB) |
| Bronze Tandem PPO 6250/65 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.9MB) |
English (PDF, 1.1MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997KB) Spanish (PDF, 863 KB) |
| Bronze Full PPO 6500/70 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.9MB) |
English (PDF, 1.1MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997KB) Spanish (PDF, 863 KB) |
| Bronze Tandem PPO 6500/70 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.9MB) |
English (PDF, 1.1MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997KB) Spanish (PDF, 863 KB) |
| Bronze Full PPO 7500/65 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.9MB) |
English (PDF, 1.1MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997KB) Spanish (PDF, 863 KB) |
| Bronze Tandem PPO 7500/65 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.9MB) |
English (PDF, 1.1MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997KB) Spanish (PDF, 863 KB) |
| Bronze Full PPO 6850/55 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.9MB) |
English (PDF, 1.1MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997KB) Spanish (PDF, 863 KB) |
| Bronze Tandem PPO 6850/55 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.9MB) |
English (PDF, 1.1MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997KB) Spanish (PDF, 863 KB) |
Virtual Blue plans
| Virtual Blue Plans | Summary of Benefits | Disclosures | Optional Benefit |
|---|---|---|---|
| Virtual Blue℠ Gold Tandem PPO 1500/45 OffEx | English (PDF, 275KB) Spanish (PDF, 344KB) |
English (PDF, 310KB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997KB) Spanish (PDF, 863 KB) |
| Virtual Blue℠ Bronze Tandem PPO 7500/75 OffEx | English (PDF, 288KB) Spanish (PDF, 353KB) |
English (PDF, 310KB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997KB) Spanish (PDF, 863 KB) |
| Virtual Blue℠ Platinum Tandem PPO 250/20 OffEx | English (PDF, 288KB) Spanish (PDF, 353KB) |
English (PDF, 310KB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997KB) Spanish (PDF, 863 KB) |
| Virtual Blue℠ Silver Tandem PPO 2700/75 OffEx | English (PDF, 288KB) Spanish (PDF, 353KB) |
English (PDF, 310KB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997KB) Spanish (PDF, 863 KB) |
Mirror package for Small Business – PPO plans
| Blue Shield Mirror PPO Plans | Summary of Benefits | Disclosures | Optional Benefit |
|---|---|---|---|
| Blue Shield Platinum 90 PPO 0/15 PCP + Child Dental | English (PDF, 1.1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 1 MB) Spanish (PDF, 863 KB) |
| Blue Shield Gold 80 PPO 350/25 PCP + Child Dental | English (PDF, 1.1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 1 MB) Spanish (PDF, 863 KB) |
| Blue Shield Silver 70 PPO 2500/55 PCP + Child Dental | English (PDF, 1.1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 1 MB) Spanish (PDF, 863 KB) |
| Blue Shield Bronze 60 PPO 5800/60 PCP + Child Dental | English (PDF, 1.1 MB) Spanish (PDF, 1.9 MB) |
English (PDF, 1.1 MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 1 MB) Spanish (PDF, 863 KB) |
| Blue Shield Bronze 60 HDHP PPO 7500/0% PCP + Child Dental Alt | English (PDF, 257 KB) Spanish (PDF, 330 KB) |
English (PDF, 340 KB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 1 MB) Spanish (PDF, 863 KB) |
| Blue Shield Silver 70 HDHP PPO 2300/30% PCP + Child Dental Alt | English (PDF, 267 KB) Spanish (PDF, 331 KB) |
English (PDF, 340 KB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 1 MB) Spanish (PDF, 863 KB) |
Off-exchange package for Small Business – HSA/HDHP plans
| Blue Shield Off-Exchange HSA HDHP Plans | Summary of Benefits | Disclosures | Optional Benefit |
|---|---|---|---|
| Gold Full PPO Savings 1750/15% HDHP PrevRx OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997 KB) Spanish (PDF, 863 KB) |
| Gold Tandem PPO Savings 1750/15% HDHP PrevRx OffEx | English (PDF, 1 MB) Spanish (PDF, 1.9 MB) |
English (PDF, 1.1 MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997 KB) Spanish (PDF, 863 KB) |
| Silver Full PPO Savings 2300/30% OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997 KB) Spanish (PDF, 863 KB) |
| Silver Tandem PPO Savings 2300/30% OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997 KB) Spanish (PDF, 863 KB) |
| Silver Full PPO Savings 2600/35% HDHP PrevRx OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997 KB) Spanish (PDF, 863 KB) |
| Silver Tandem PPO Savings 2600/35% HDHP PrevRx OffEx | English (PDF, 1 MB) Spanish (PDF, 1.9 MB) |
English (PDF, 1.1 MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997 KB) Spanish (PDF, 863 KB) |
| Bronze Full PPO Savings 5700/40% OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997 KB) Spanish (PDF, 863 KB) |
| Bronze Tandem PPO Savings 5700/40% OffEx | English (PDF, 1 MB) Spanish (PDF, 1.9 MB) |
English (PDF, 1.1 MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997 KB) Spanish (PDF, 863 KB) |
| Bronze Full PPO Savings 7500 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997 KB) Spanish (PDF, 863 KB) |
| Bronze Tandem PPO Savings 7500 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility Effective 1/1 English (PDF, 532 KB) Spanish (PDF, 684 KB) Effective 7/1 English (PDF, 997 KB) Spanish (PDF, 863 KB) |
