Summary of Benefits 2025
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) |
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