Summary of Benefits 2026

 

The SOB documents will include the coverage information you are used to seeing but in a much-simplified format. The format makes it easier for members to read and understand their plan benefits. SOBs will be included in new business proposals and renewals, open-enrollment materials, as well as member welcome kits as part of the Evidence of Coverage (EOC).

When providing the Summary of Benefits to an applicant or Blue Shield member, you must also include a Notice of Language Assistance (PDF, 1.1 MB).

In addition, the Summary of Benefits and Coverage (SBC) Forms provide your clients with an easy-to-understand overview of what our plans for groups of 101 and above cover. You can download SBC Forms and other resources for these plans:

  • PPO plans
  • HMO plans
  • HSA-compatible plans
  • Trio HMO plans
  • Point of service (POS) plans
  • Prescription drug options

HMO plans

Prescription drug options

Access+ HMO plans Summary of Benefits Optional benefits Disclosures
Access+ HMO® Zero Admit 10 English (PDF, 1 MB)
Spanish (PDF, 525 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Access+ HMO® Zero Admit 15 English (PDF, 1 MB)
Spanish (PDF, 525 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Access+ HMO® Zero Admit 20 English (PDF, 1 MB)
Spanish (PDF, 525 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Access+ HMO® Zero Admit 30 English (PDF, 1 MB)
Spanish (PDF, 525 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Access+ HMO® Per Admit 10-250 English (PDF, 1 MB)
Spanish (PDF, 526 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Access+ HMO® Per Admit 20-250 English (PDF, 1 MB)
Spanish (PDF, 562 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Access+ HMO® Per Admit 20-500 English (PDF, 1 MB)
Spanish (PDF, 525 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Access+ HMO® Per Admit 25-750 English (PDF, 1 MB)
Spanish (PDF, 525 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Access+ HMO® Per Admit 40-1000 English (PDF, 1 MB)
Spanish (PDF, 525 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Access+ HMO® Per Day 15-500 English (PDF, 1 MB)
Spanish (PDF, 527 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Access+ HMO® Per Day 20-250 English (PDF, 1 MB)
Spanish (PDF, 526 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Access+ HMO® Per Day 20-500 English (PDF, 1 MB)
Spanish (PDF, 526 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Access+ HMO® Per Day 25-750 English (PDF, 1 MB)
Spanish (PDF, 526 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Access+ HMO® Per Day 30-500 English (PDF, 1 MB)
Spanish (PDF, 526 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Access+ HMO® Facility Coinsurance
15-20%		 English (PDF, 1 MB)
Spanish (PDF, 526 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Access+ HMO® Facility Coinsurance
20-20%		 English (PDF, 1 MB)
Spanish (PDF, 526 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Access+ HMO® Facility Coinsurance
25-25%		 English (PDF, 1 MB)
Spanish (PDF, 526 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Access+ HMO® Facility Coinsurance 30-30% English (PDF, 1 MB)
Spanish (PDF, 526 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Access+ HMO® Facility Coinsurance
40-40%		 English (PDF, 1 MB)
Spanish (PDF, 526 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Access+ HMO® Zero Facility Deductible
30-20%		 English (PDF, 1 MB)
Spanish (PDF, 526 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Access+ HMO® Facility Deductible 15-10%/250 English (PDF, 1 MB)
Spanish (PDF, 533 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Access+ HMO® Facility Deductible 15-10%/500 English (PDF, 1 MB)
Spanish (PDF, 533 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Access+ HMO® Facility Deductible 15-10%/750 English (PDF, 1 MB)
Spanish (PDF, 533 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Access+ HMO® Facility Deductible
15-10%/1500		 English (PDF, 1 MB)
Spanish (PDF, 532 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Access+ HMO® Facility Deductible
20-25%/1500		 English (PDF, 1 MB)
Spanish (PDF, 532 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Access+ HMO® Facility Deductible
30-10%/1500		 English (PDF, 1 MB)
Spanish (PDF, 533 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Access+ HMO® Facility Deductible 30-30%/2000 English (PDF, 1 MB)
Spanish (PDF, 533 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Access+ HMO® Facility Deductible 40-40%/2000 English (PDF, 1 MB)
Spanish (PDF, 533 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Access+ HMO® Facility Deductible 40-40%/5800 English (PDF, 1 MB)
Spanish (PDF, 533 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Local Access+ HMO plans Summary of Benefits Optional benefits Disclosures
Local Access+ HMO® Facility Coinsurance 15-20% English (PDF, 1 MB)
Spanish (PDF, 526 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Local Access+ HMO® Facility Coinsurance 40-40% English (PDF, 1 MB)
Spanish (PDF, 526 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Local Access+ HMO® Per Admit 25-750 English (PDF, 1 MB)
Spanish (PDF, 252)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Local Access+ HMO® Zero Admit 10 English (PDF, 1 MB)
Spanish (PDF, 525 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Local Access+ HMO® Per Admit 10-250 English (PDF, 1 MB)
Spanish (PDF, 525 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Local Access+ HMO® Per Admit 20-500 English (PDF, 1 MB)
Spanish (PDF, 525 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Local Access+ HMO® Facility Coinsurance 25-25% English (PDF, 1 MB)
Spanish (PDF, 526 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Local Access+ HMO® Zero Admit 20 English (PDF, 1 MB)
Spanish (PDF, 525 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Local Access+ HMO® Zero Admit 30 English (PDF, 1 MB)
Spanish (PDF, 525 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Local Access+ HMO® Per Admit 40-1000 English (PDF, 1 MB)
Spanish (PDF, 526 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Local Access+ HMO® Facility Coinsurance 20-20% English (PDF, 1 MB)
Spanish (PDF, 526 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Local Access+ HMO® Facility Deductible 15-10%/1500 English (PDF, 1 MB)
Spanish (PDF, 532 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Local Access+ HMO® Facility Deductible 20-25%/1500 English (PDF, 1 MB)
Spanish (PDF, 532 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Local Access+ HMO® Facility Deductible 30-30%/2000 English (PDF, 1 MB)
Spanish (PDF, 532 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Local Access+ HMO® Facility Deductible 40-40%/2000 English (PDF, 1 MB)
Spanish (PDF, 532 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Local Access+ HMO® Per Admit 20-250 English (PDF, 1 MB)
Spanish (PDF, 525 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Local Access+ HMO® Per Day 20-250 English (PDF, 1 MB)
Spanish (PDF, 527)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Local Access+ HMO® Per Day 20-500 English (PDF, 1 MB)
Spanish (PDF, 526 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Local Access+ HMO® Per Day 30-500 English (PDF, 1 MB)
Spanish (PDF, 526 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Local Access+ HMO® Facility Coinsurance 30-30% English (PDF, 1 MB)
Spanish (PDF, 526 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Local Access+ HMO® Facility Deductible 15-10%/250 English (PDF, 1 MB)
Spanish (PDF, 533 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Local Access+ HMO® Facility Deductible 15-10%/500 English (PDF, 1 MB)
Spanish (PDF, 553 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Local Access+ HMO® Facility Deductible 15-10%/750 English (PDF, 1 MB)
Spanish (PDF, 533 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Local Access+ HMO® Facility Deductible 30-10%/1500 English (PDF, 1 MB)
Spanish (PDF, 533 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Local Access+ HMO® Per Day 15-500 English (PDF, 1 MB)
Spanish (PDF, 526 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Local Access+ HMO® Per Day 25-750 English (PDF, 1 MB)
Spanish (PDF, 526 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Local Access+ HMO® Zero Admit 15 English (PDF, 1 MB)
Spanish (PDF, 525 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Local Access+ HMO® Zero Facility Deductible 30-20% English (PDF, 1 MB)
Spanish (PDF, 526 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Local Access+ HMO® Facility Deductible 40-40%/5800 English (PDF, 1 MB)
Spanish (PDF, 533 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Trio HMO plans Summary of Benefits Optional benefits Disclosures
Trio HMO Zero Admit 10 English (PDF, 1 MB)
Spanish (PDF, 525 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Trio HMO Zero Admit 15 English (PDF, 1 MB)
Spanish (PDF, 525 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Trio HMO Zero Admit 20 English (PDF, 1 MB)
Spanish (PDF, 525 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Trio HMO Zero Admit 30 English (PDF, 1 MB)
Spanish (PDF, 525 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Trio HMO Per Admit 10-250 English (PDF, 1 MB)
Spanish (PDF, 525 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Trio HMO Per Admit 20-250 English (PDF, 1 MB)
Spanish (PDF, 525 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Trio HMO Per Admit 20-500 English (PDF, 1 MB)
Spanish (PDF, 525 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Trio HMO Per Admit 25-750 English (PDF, 1 MB)
Spanish (PDF, 525 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Trio HMO Per Admit 40-1000 English (PDF, 1 MB)
Spanish (PDF, 525 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Trio HMO Per Day 15-500 English (PDF, 1 MB)
Spanish (PDF, 525 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Trio HMO Per Day 25-750 English (PDF, 1 MB)
Spanish (PDF, 526 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Trio HMO Per Day 20-250 English (PDF, 1 MB)
Spanish (PDF, 525 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Trio HMO Per Day 20-500 English (PDF, 1 MB)
Spanish (PDF, 525 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Trio HMO Per Day 30-500 English (PDF, 1 MB)
Spanish (PDF, 525 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Trio HMO Facility Coinsurance 15-20% English (PDF, 1 MB)
Spanish (PDF, 526 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Trio HMO Facility Coinsurance 20-20% English (PDF, 1 MB)
Spanish (PDF, 525 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Trio HMO Facility Coinsurance 25-25% English (PDF, 1 MB)
Spanish (PDF, 525 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Trio HMO Facility Coinsurance 30-30% English (PDF, 1 MB)
Spanish (PDF, 525 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Trio HMO Facility Coinsurance 40-40% English (PDF, 1 MB)
Spanish (PDF, 526 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Trio HMO Zero Facility Deductible 30-20% English (PDF, 1 MB)
Spanish (PDF, 525 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Trio HMO Facility Deductible 15-10%/250 English (PDF, 1 MB)
Spanish (PDF, 532 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Trio HMO Facility Deductible 15-10%/500 English (PDF, 1 MB)
Spanish (PDF, 532 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Trio HMO Facility Deductible 15-10%/750 English (PDF, 1 MB)
Spanish (PDF, 532 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Trio HMO Facility Deductible 15-10%/1500 English (PDF, 1 MB)
Spanish (PDF, 532 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Trio HMO Facility Deductible 20-25%/1500 English (PDF, 1 MB)
Spanish (PDF, 532 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Trio HMO Facility Deductible 30-10%/1500 English (PDF, 1 MB)
Spanish (PDF, 532 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Trio HMO Facility Deductible 30-30%/2000 English (PDF, 1 MB)
Spanish (PDF, 532 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Trio HMO Facility Deductible 40-40%/2000 English (PDF, 1 MB)
Spanish (PDF, 532 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)
Trio HMO Facility Deductible 40-40%/5800 English (PDF, 1 MB)
Spanish (PDF, 533 KB)		 English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434KB)		 English (1.1 MB)

PPO plans

Prescription drug options

Full PPO plans Summary of Benefits Optional benefits Disclosures
Full PPO No Network Deductible 10 100/50 English (PDF, 1 MB)
Spanish (PDF, 583 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full PPO No Network Deductible 20 100/50 English (PDF, 1 MB)
Spanish (PDF, 582 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full PPO No Network Deductible 15 90/60 English (PDF, 1 MB)
Spanish (PDF, 585 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full PPO No Network Deductible 25 80/60 English (PDF, 1 MB)
Spanish (PDF, 585 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full PPO Combined Deductible 0-250 80/60 English (PDF, 1 MB)
Spanish (PDF, 589 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full PPO Combined Deductible 0-250 90/70 English (PDF, 1 MB)
Spanish (PDF, 589 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full PPO Combined Deductible 0-400 90/70 English (PDF, 1 MB)
Spanish (PDF, 589 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full PPO Combined Deductible 10-250 90/70 English (PDF, 1 MB)
Spanish (PDF, 589 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full PPO Combined Deductible 10-500 90/70 English (PDF, 1 MB)
Spanish (PDF, 589 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full PPO Combined Deductible 15-250 90/70 English (PDF, 1 MB)
Spanish (PDF, 589 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full PPO Combined Deductible 20-200 90/70 English (PDF, 1 MB)
Spanish (PDF, 589 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full PPO Combined Deductible 20-250 80/60 English (PDF, 1 MB)
Spanish (PDF, 589 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full PPO Combined Deductible 25-250 80/60 English (PDF, 1 MB)
Spanish (PDF, 589 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full PPO Combined Deductible 25-250 90/60 English (PDF, 1 MB)
Spanish (PDF, 589 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full PPO Combined Deductible 30-500 90/60 English (PDF, 1 MB)
Spanish (PDF, 589 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full PPO Combined Deductible 30-750 80/60 English (PDF, 1 MB)
Spanish (PDF, 589 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full PPO Combined Deductible 35-500 80/60 English (PDF, 1 MB)
Spanish (PDF, 589 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full PPO Combined Deductible 40-6350 80/50 English (PDF, 1 MB)
Spanish (PDF, 589 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full PPO Combined Deductible 20-250 90/70 English (PDF, 1 MB)
Spanish (PDF, 589 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full PPO Combined Deductible 20-500 80/60 English (PDF, 1 MB)
Spanish (PDF, 589 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full PPO Combined Deductible 25-750 80/60 English (PDF, 1 MB)
Spanish (PDF, 589 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full PPO Combined Deductible Value 10-1000 90/70 English (PDF, 1 MB)
Spanish (PDF, 589 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full PPO Combined Deductible Value 15-1500 80/50 English (PDF, 1 MB)
Spanish (PDF, 589 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full PPO Combined Deductible Value 20-2000 80/50 English (PDF, 1 MB)
Spanish (PDF, 589 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full PPO Combined Deductible Value 25-2500 80/50 English (PDF, 1 MB)
Spanish (PDF, 589 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full PPO Combined Deductible Value 30-3000 80/50 English (PDF, 1 MB)
Spanish (PDF, 589 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full PPO Combined Deductible Value 40-4000 80/50 English (PDF, 1 MB)
Spanish (PDF, 589 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full PPO Combined Deductible 10-250 90/70 English (PDF, 1 MB)
Spanish (PDF, 589 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Shield Spectrum PPOSM 250 90/70 Standard English (PDF, 1 MB)
Spanish (PDF, 613 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full PPO Split Deductible 0-1750 80/60 English (PDF, 1 MB)
Spanish (PDF, 590 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full PPO Split Deductible 0-500 80/60 English (PDF, 1 MB)
Spanish (PDF, 590 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full PPO Split Deductible 10-250 90/70 English (PDF, 1 MB)
Spanish (PDF, 589 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full PPO Split Deductible 15-500 90/60 English (PDF, 1 MB)
Spanish (PDF, 590 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full PPO Split Deductible 20-500 80/60 English (PDF, 1 MB)
Spanish (PDF, 593 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full PPO Split Deductible 25-750 80/60 English (PDF, 1 MB)
Spanish (PDF, 590 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full PPO Split Deductible 30-2000 70/50 English (PDF, 1 MB)
Spanish (PDF, 590 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full PPO Split Deductible 35-1000 80/60 English (PDF, 1 MB)
Spanish (PDF, 590 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full PPO Split Deductible 40-4000 70/50 English (PDF, 1 MB)
Spanish (PDF, 590 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full PPO Split Deductible 50-5000 70/50 English (PDF, 1 MB)
Spanish (PDF, 590 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB))		 English (PDF, 1.1 MB)
Full PPO Split Deductible 50-6350 70/50 English (PDF, 1 MB)
Spanish (PDF, 590 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full PPO Savings Two-Tier plans Summary of Benefits Optional benefits Disclosures
Full PPO Savings Two-Tier Embedded Deductible 1700/3400/3400 90/70 English (PDF, 1 MB)
Spanish (PDF, 629 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full PPO Savings Two-Tier Embedded Deductible 1700/3400/3400 90/60 English (PDF, 1 MB)
Spanish (PDF, 629 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full PPO Savings Two-Tier Embedded Deductible 1700/3400/3400 100% English (PDF, 1 MB)
Spanish (PDF, 624 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full PPO Savings Two-Tier Embedded Deductible 1700/3400/3400 with $0 HDHP Preventive Drug Benefit English (PDF, 1 MB)
Spanish (PDF, 627 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full PPO Savings Two-Tier Embedded Deductible 1800/3400/3600 English (PDF, 1 MB)
Spanish (PDF, 627 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full PPO Savings Two-Tier Embedded Deductible 1800/3400/3600 with Value Formulary English (PDF, 1 MB)
Spanish (PDF, 629 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full PPO Savings Two-Tier Embedded Deductible 2250/3400/4500 English (PDF, 1 MB)
Spanish (PDF, 629 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full PPO Savings Two-Tier Embedded Deductible 2250/3400/4500 with $0 HDHP Preventive Drug Benefit English (PDF, 1 MB)
Spanish (PDF, 629 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full PPO Savings Two-Tier Embedded Deductible 2250/3400/4500 with Value Formulary English (PDF, 1 MB)
Spanish (PDF, 629 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full PPO Savings Two-Tier Embedded Deductible 1700/3400/3400 with Value Formulary English (PDF, 1 MB)
Spanish (PDF, 629 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Tandem PPO Savings Two-Tier Embedded Deductible 1700/3400/3400 English (PDF, 1 MB)
Spanish (PDF, 629 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full PPO Savings plans Summary of Benefits Optional benefits Disclosures
Full PPO Savings Embedded Deductible 3400/5200 English (PDF, 1 MB)
Spanish (PDF, 628 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full PPO Savings Embedded Deductible 3400/6000 English (PDF, 1 MB)
Spanish (PDF, 628 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full PPO Savings Embedded Deductible 3400 100% English (PDF, 1 MB)
Spanish (PDF, 625 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full PPO Savings Embedded Deductible 3500 English (PDF, 1 MB)
Spanish (PDF, 628 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full PPO Savings Embedded Deductible 4000 English (PDF, 1 MB)
Spanish (PDF, 589 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full PPO Savings Embedded Deductible 4400 100% English (PDF, 1 MB)
Spanish (PDF, 625 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full PPO Savings Embedded Deductible 5500 English (PDF, 1 MB)
Spanish (PDF, 628 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full PPO Savings Embedded Deductible 5500 with Value Formulary English (PDF, 1 MB)
Spanish (PDF, 629 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full PPO Savings Embedded Deductible 6350 100% English (PDF, 1 MB)
Spanish (PDF, 625 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full PPO Savings Embedded Deductible 3400 100% with Value Formulary English (PDF, 1 MB)
Spanish (PDF, 625 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full PPO Savings Embedded Deductible 3500 with Value Formulary English (PDF, 1 MB)
Spanish (PDF, 629 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full PPO Savings Embedded Deductible 4000 with Value Formulary English (PDF, 1 MB)
Spanish (PDF, 629 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full PPO Savings Embedded Deductible 4400 100% with Value Formulary English (PDF, 1 MB)
Spanish (PDF, 625 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full PPO Savings Embedded Deductible 6350 100% with Value Formulary English (PDF, 1 MB)
Spanish (PDF, 625 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Tandem PPO plans Summary of Benefits Optional benefits Disclosures
Tandem PPO Combined Deductible 10-250 90/70 English (PDF, 1 MB)
Spanish (PDF, 589 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Tandem PPO Combined Deductible 15-250 90/70 English (PDF, 1 MB)
Spanish (PDF, 589 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Tandem PPO Combined Deductible 20-200 90/70 English (PDF, 1 MB)
Spanish (PDF, 589 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Tandem PPO Combined Deductible 20-250 80/60 English (PDF, 1 MB)
Spanish (PDF, 589 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Tandem PPO Combined Deductible 25-250 80/60 English (PDF, 1 MB)
Spanish (PDF, 589 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Tandem PPO Combined Deductible 25-250 90/60 English (PDF, 1 MB)
Spanish (PDF, 589 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Tandem PPO Combined Deductible Value 10-1000 90/70 English (PDF, 1 MB)
Spanish (PDF, 589 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Tandem PPO No Network Deductible 10 100/50 English (PDF, 1 MB)
Spanish (PDF, 583 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Tandem PPO Split Deductible 10-250 90/70 English (PDF, 1 MB)
Spanish (PDF, 590 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Tandem PPO Split Deductible 20-500 80/60 English (PDF, 1 MB)
Spanish (PDF, 590 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Tandem PPO Split Deductible 25-750 80/60 English (PDF, 1 MB)
Spanish (PDF, 590 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Tandem PPO Split Deductible 35-1000 80/60 English (PDF, 1 MB)
Spanish (PDF, 590 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Tandem PPO Split Deductible 30-1500 80/50 English (PDF, 1 MB)
Spanish (PDF, 590 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Tandem PPO Split Deductible 40-3000 70/50 English (PDF, 1 MB)
Spanish (PDF, 589 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Tandem PPO Combined Deductible 0-400 90/70 English (PDF, 1 MB)
Spanish (PDF, 589 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Tandem PPO Split Deductible 0-1750 80/60 English (PDF, 1 MB)
Spanish (PDF, 590 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Tandem PPO Split Deductible 0-500 80/60 English (PDF, 1 MB)
Spanish (PDF, 590 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Tandem PPO Combined Deductible 0-250 80/60 English (PDF, 1 MB)
Spanish (PDF, 589 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Tandem PPO Combined Deductible 0-250 90/70 English (PDF, 1 MB)
Spanish (PDF, 589 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Tandem PPO Savings plans Summary of Benefits Optional benefits Disclosures
Tandem PPO Savings Embedded Deductible 3400 English (PDF, 1 MB)
Spanish (PDF, 628 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Tandem PPO Savings Embedded Deductible 4425 English (PDF, 1 MB)
Spanish (PDF, 629 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Tandem PPO Savings Embedded Deductible 3400 100% English (PDF, 1 MB)
Spanish (PDF, 625 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Tandem PPO Savings Embedded Deductible 5500 English (PDF, 1 MB)
Spanish (PDF, 528 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Tandem PPO Savings Embedded Deductible 6350 100% English (PDF, 1 MB)
Spanish (PDF, 625 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Virtual Blue PPO plans Summary of Benefits Optional benefits Disclosures
Virtual BlueSM PPO Combined Deductible 20-250 80/60 English (PDF, 1 MB)
Spanish (PDF, 613 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Virtual BlueSM PPO Split Deductible 50-1000 70/50 English (PDF, 1 MB)
Spanish (PDF, 614 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Virtual BlueSM PPO Split Deductible 50-3000 60/50 English (PDF, 1 MB)
Spanish (PDF, 614 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Virtual BlueSM PPO Savings Embedded Deductible 5500 English (PDF, 1 MB)
Spanish (PDF, 652 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Virtual BlueSM PPO Savings Two-Tier Embedded Deductible 2500/3400/5000 English (PDF, 1 MB)
Spanish (PDF, 653 KB )		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Virtual BlueSM PPO Combined Deductible 20-250 90/70 English (PDF, 1 MB)
Spanish (PDF, 613 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Virtual BlueSM PPO Combined Deductible 20-500 80/60 English (PDF, 1 MB)
Spanish (PDF, 613 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Virtual BlueSM PPO Split Deductible 20-250 90/70 English (PDF, 1 MB)
Spanish (PDF, 614 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Virtual BlueSM PPO Split Deductible 20-500 80/60 English (PDF, 1 MB)
Spanish (PDF, 614 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Virtual BlueSM PPO Split Deductible 20-750 80/60 English (PDF, 1 MB)
Spanish (PDF, 614 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Virtual BlueSM PPO Split Deductible 20-1000 80/60 English (PDF, 1 MB)
Spanish (PDF, 614 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Virtual BlueSM PPO Split Deductible 20-1500 80/60 English (PDF, 1 MB)
Spanish (PDF, 614 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Virtual BlueSM PPO Split Deductible 20-2000 70/50 English (PDF, 1 MB)
Spanish (PDF, 614 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Virtual BlueSM Full PPO Combined Deductible 15-250 90/70 English (PDF, 1 MB)
Spanish (PDF, 613 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Virtual BlueSM Full PPO No-Network Deductible 10 100/50 English (PDF, 1 MB)
Spanish (PDF, 607 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Virtual BlueSM Full PPO Split Deductible 20-500 80/60 English (PDF, 1 MB)
Spanish (PDF, 614 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Virtual BlueSM Full PPO Savings Embedded Deductible 3400 100% English (PDF, 1 MB)
Spanish (PDF, 649 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Virtual BlueSM Full PPO Savings Embedded Deductible 5500 English (PDF, 1 MB)
Spanish (PDF, 654 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Virtual BlueSM Full PPO Savings Two-Tier Embedded Deductible 1700/3400/3400 English (PDF, 1 MB)
Spanish (PDF, 653 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Virtual BlueSM PPO Savings Embedded Deductible 3400 English (PDF, 1 MB)
Spanish (PDF, 652 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Virtual BlueSM PPO Savings Embedded Deductible 3400 100% English (PDF, 1 MB)
Spanish (PDF, 649 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Virtual BlueSM PPO Savings Two-Tier Embedded Deductible 1800/3400/3600 English (PDF, 1 MB)
Spanish (PDF, 653 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Virtual BlueSM PPO Savings Two-Tier Embedded Deductible 1700/3400/3400 English (PDF, 1 MB)
Spanish (PDF, 651 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Virtual BlueSM PPO Savings Embedded Deductible 4400 100% English (PDF, 1 MB)
Spanish (PDF, 649 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Virtual BlueSM Full PPO Split Deductible 10-250 90/70 English (PDF, 1 MB)
Spanish (PDF, 614 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Virtual BlueSM Full PPO Split Deductible 35-1000 80/60 English (PDF, 1 MB)
Spanish (PDF, 614 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Virtual BlueSM Full PPO Savings Embedded Deductible 3400 English (PDF, 1 MB)
Spanish (PDF, 652 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Active Choice PPO plans Summary of Benefits Optional benefits Disclosures
Active Choice® Plus 300 20 80/60 English (PDF, 1 MB)
Spanish (PDF, 615 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Active Choice® Plus 300 80/60 English (PDF, 1 MB)
Spanish (PDF, 615 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Active Choice® Plus 1000 20 80/60 English (PDF, 1 MB)
Spanish (PDF, 615 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Active Choice® Plus 1000 80/60 English (PDF, 1 MB)
Spanish (PDF, 615 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Active Choice® Plus 1000 80/60 1000 Deductible English (PDF, 1 MB)
Spanish (PDF, 619 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Active Choice® Plus 300 80/60 2000 Deductible English (PDF, 1 MB)
Spanish (PDF, 619 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Active Choice® Classic 600 80/50 English (PDF, 1 MB)
Spanish (PDF, 573 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Active Choice® Classic 850 70/50 1000 Deductible English (PDF, 1 MB)
Spanish (PDF, 577 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Active Choice® Classic 850 80/60 English (PDF, 1 MB)
Spanish (PDF, 573 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Active Choice® Classic 600 70/50 2000 Deductible English (PDF, 1 MB)
Spanish (PDF, 577 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)

Added Advantage Point of Service plans

Added Advantage POSSM plans Summary of Benefits Optional benefits Disclosures
Added Advantage POSSM 500-100/80/60 English (PDF, 1 MB)
Spanish (PDF, 644 KB)		 English
Chiropractic (PDF, 987 KB)
Chiropractic and acupuncture (PDF, 987 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Added Advantage POSSM 300-100/90/70 English (PDF, 1 MB)
Spanish (PDF, 644 KB)		 English
Chiropractic (PDF, 987 KB)
Chiropractic and acupuncture (PDF, 987 KB)
Hearing aid (PDF, 987 KB)
Spanish
Chiropractic (PDF, 447 KB)
Chiropractic and acupuncture (PDF, 456 KB)
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)

EPO plans

Prescription drug options

Full EPO plans Summary of Benefits Optional benefits Disclosures
Full EPO Zero Admit 20 English (PDF, 1 MB)
Spanish (PDF, 538 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full EPO Zero Admit 30 English (PDF, 1 MB)
Spanish (PDF, 538 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full EPO Per Admit 10-250 English (PDF, 1 MB)
Spanish (PDF, 538 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full EPO Facility Coinsurance 20-20% English (PDF, 1 MB)
Spanish (PDF, 539 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full EPO 25-1500 80% English (PDF, 1 MB)
Spanish (PDF, 547 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full EPO 25-2500 80% English (PDF, 1 MB)
Spanish (PDF, 547 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full EPO 10-250 90% English (PDF, 1 MB)
Spanish (PDF, 547 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full EPO 20-500 80% English (PDF, 1 MB)
Spanish (PDF, 547 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full EPO Per Admit 15-100 English (PDF, 1 MB)
Spanish (PDF, 538 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full EPO 25-2500 80% with BlueHPN® English (PDF, 1 MB)
Spanish (PDF, 547 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Full EPO Per Admit 10-250 with BlueHPN® English (PDF, 1 MB)
Spanish (PDF, 539 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Tandem EPO plans Summary of Benefits Optional benefits Disclosures
Tandem EPO Zero Admit 20 English (PDF, 1 MB)
Spanish (PDF, 538 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Tandem EPO Zero Admit 30 English (PDF, 1 MB)
Spanish (PDF, 538 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Tandem EPO Per Admit 10-250 English (PDF, 1 MB)
Spanish (PDF, 538 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Tandem EPO Facility Coinsurance 20-20% English (PDF, 1 MB)
Spanish (PDF, 539 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Tandem EPO 25-1500 80% English (PDF, 1 MB)
Spanish (PDF, 547 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Tandem EPO 25-2500 80% English (PDF, 1 MB)
Spanish (PDF, 547 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Tandem EPO 20-500 80% English (PDF, 1 MB)
Spanish (PDF, 547 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Tandem EPO 10-250 90% English (PDF, 1 MB)
Spanish (PDF, 547 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Tandem EPO 25-2500 80% with BlueHPN® English (PDF, 1 MB)
Spanish (PDF, 547 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Tandem EPO Per Admit 10-250 with BlueHPN® English (PDF, 1 MB)
Spanish (PDF, 539 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)

Virtual Blue EPO plans

Prescription drug options

Virtual Blue EPO plans Summary of Benefits Optional benefits Disclosures
Virtual BlueSM EPO 20-1000 80% English (PDF, 1 MB)
Spanish (PDF, 571 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Virtual BlueSM EPO 20-1500 80% English (PDF, 1 MB)
Spanish (PDF, 571 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Virtual BlueSM EPO 20-2000 70% English (PDF, 1 MB)
Spanish (PDF, 571 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Virtual BlueSM EPO 20-250 80% English (PDF, 1 MB)
Spanish (PDF, 571 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Virtual BlueSM EPO 20-250 90% English (PDF, 1 MB)
Spanish (PDF, 571 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Virtual BlueSM EPO 20-500 80% English (PDF, 1 MB)
Spanish (PDF, 571 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Virtual BlueSM EPO 20-750 80% English (PDF, 1 MB)
Spanish (PDF, 571 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Virtual BlueSM EPO 50-1000 70% English (PDF, 1 MB)
Spanish (PDF, 571 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Virtual BlueSM EPO 50-3000 60% English (PDF, 1 MB)
Spanish (PDF, 570 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Virtual BlueSM EPO Savings Embedded Deductible 3400 100% English (PDF, 1 MB)
Spanish (PDF, 613 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Virtual BlueSM EPO Savings Embedded Deductible 4400 100% English (PDF, 1 MB)
Spanish (PDF, 613 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Virtual BlueSM Full EPO 20-500 80% English (PDF, 1 MB)
Spanish (PDF, 571 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Virtual BlueSM EPO Savings Embedded Deductible 5500 English (PDF, 1 MB)
Spanish (PDF, 615 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Virtual BlueSM EPO Savings Two-Tier Embedded Deductible 2500/3400/5000 English (PDF, 1 MB)
Spanish (PDF, 615 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Virtual BlueSM EPO Savings Embedded Deductible 3400 English (PDF, 1 MB)
Spanish (PDF, 615 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Virtual BlueSM EPO Savings Two-Tier Embedded Deductible 1700/3400/3400 English (PDF, 1 MB)
Spanish (PDF, 615 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Virtual BlueSM EPO Savings Two-Tier Embedded Deductible 1800/3400/3600 English (PDF, 1 MB)
Spanish (PDF, 615 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)
Virtual BlueSM Full EPO Savings Embedded Deductible 3400 English (PDF, 1 MB)
Spanish (PDF, 615 KB)		 English
Hearing aid (PDF, 987 KB)
Spanish
Hearing aid (PDF, 434 KB)		 English (PDF, 1.1 MB)

© California Physicians' Service DBA Blue Shield of California 1999-2025. All rights reserved. California Physicians’ Service DBA Blue Shield of California is an independent member of the Blue Shield Association. Health insurance products are offered by Blue Shield of California Life & Health Insurance Company. Health plans are offered by Blue Shield of California.

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