Summary of Benefits 2023
For 2023 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. Download SBC forms and other resources.
These SOBs are effective January 1, 2023, 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 English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Platinum Local Access+ HMO® 0/20 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Platinum Trio HMO 0/20 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Platinum Access+ HMO® 0/25 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Platinum Local Access+ HMO® 0/25 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Platinum Trio HMO 0/25 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Platinum Access+ HMO® 0/30 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Platinum Local Access+ HMO® 0/30 OffEx | English (PDF, 1MB) Spanish (PDF, 1.8MB) |
English (PDF, 1.1 MB) |
Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Platinum Trio HMO 0/30 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Gold Access+ HMO® 0/30 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Gold Local Access+ HMO® 0/30 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Gold Trio HMO 0/30 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Gold Access+ HMO® 500/35 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Gold Local Access+ HMO® 500/35 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Gold Trio HMO 500/35 OffEx | English (PDF, iMB) Spanish (PDF, 1.8MB) |
English (PDF, 1.1 MB) |
Infertility English (PDF, 996.9KB) Spanish (PDF, 1.7MB) |
| Gold Access+ HMO® 1000/35 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Gold Local Access+ HMO® 1000/35 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Gold Trio HMO 1000/35 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Gold Access+ HMO® 1500/35 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Gold Local Access+ HMO® 1500/35 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Gold Trio HMO 1500/35 OffEx | English (PDF, 49 KB) Spanish (PDF, 49 KB) |
English (PDF, 1.1 MB) |
Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Silver Access+ HMO® 2300/70 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Silver Access+ HMO® 2750/70 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Silver Local Access+ HMO® 2300/70 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Silver Local Access+ HMO® 2750/70 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Silver Trio HMO 2300/70 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Silver Trio HMO 2750/70 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Bronze Access+ HMO® 7000/70 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Bronze Local Access+ HMO 7000/70 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8MB) |
English (PDF, 1.1 MB) |
Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Bronze Trio HMO 7000/70 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
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 + Child Dental |
English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility English (PDF, 1.0 MB) Spanish (PDF, 1.7 MB) |
| Blue Shield Trio Gold 80 HMO 250/35 + Child Dental |
English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility English (PDF, 1.0 MB) Spanish (PDF, 1.7 MB) |
| Blue Shield Trio Silver 70 HMO 2500/55 + Child Dental |
English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility English (PDF, 1.0 MB) Spanish (PDF, 1.7 MB) |
| Blue Shield Access+ Gold 80 HMO® 250/35 + Child Dental | English (PDF, 227 KB) Spanish (PDF, 276 KB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 1.0 MB) Spanish (PDF, 1.7 MB) |
| Blue Shield Access+ Platinum 90 HMO® 0/20 + Child Dental | English (PDF, 218 KB) Spanish (PDF, 263 KB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 1.0 MB) Spanish (PDF, 1.7 MB) |
| Blue Shield Access+ Silver 70 HMO® 2500/55 + Child Dental | English (PDF, 220 KB) Spanish (PDF, 267 KB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 1.0 MB) Spanish (PDF, 1.7 MB) |
| Blue Shield Bronze Trio 7000/70 + Child Dental | English (PDF, 231 KB) Spanish (PDF, 271 KB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 1.0 MB) Spanish (PDF, 1.7 MB) |
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, 1.1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 996.7 KB) Spanish (PDF, 1.7 MB) |
| Platinum Tandem PPO 0/0 OffEx | English (PDF, 1.1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility English (PDF, 996.7 KB) Spanish (PDF, 1.7 MB) |
| Platinum Full PPO 0/10 OffEx | English (PDF, 1.1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 996.7 KB) Spanish (PDF, 1.7 MB) |
| Platinum Tandem PPO 0/10 OffEx | English (PDF, 1.1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 996.7 KB) Spanish (PDF, 1.7 MB) |
| Platinum Full PPO 250/10 OffEx | English (PDF, 1.1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 996.7 KB) Spanish (PDF, 1.7 MB) |
| Platinum Tandem PPO 250/10 OffEx | English (PDF, 1.1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 996.7 KB) Spanish (PDF, 1.7 MB) |
| Platinum Full PPO 250/15 OffEx | English (PDF, 1.1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility English (PDF, 996.7 KB) Spanish (PDF, 1.7 MB) |
| Platinum Tandem PPO 250/15 OffEx | English (PDF, 1.1 MB) Spanish (PDF, 1.9 MB) |
English (PDF, 1.1 MB) |
Infertility English (PDF, 996.7 KB) Spanish (PDF, 1.7 MB) |
| Gold Full PPO 0/25 OffEx | English (PDF, 1.1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 996.7 KB) Spanish (PDF, 1.7 MB) |
| Gold Tandem PPO 0/25 OffEx | English (PDF, 1.1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 996.7 KB) Spanish (PDF, 1.7 MB) |
| Gold Full PPO 500/30 OffEx | English (PDF, 1.1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 996.7 KB) Spanish (PDF, 1.7 MB) |
| Gold Tandem PPO 500/30 OffEx | English (PDF, 1.1 MB) Spanish (PDF, 1.9 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 996.7 KB) Spanish (PDF, 1.7 MB) |
| Gold Full PPO 750/30 OffEx | English (PDF, 1.1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 996.7 KB) Spanish (PDF, 1.7 MB) |
| Gold Tandem PPO 750/30 OffEx | English (PDF, 1.1 MB) Spanish (PDF, 1.9 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 996.7 KB) Spanish (PDF, 1.7 MB) |
| Gold Full PPO 1000/35 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.8MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB) |
| Gold Tandem PPO 1000/35 OffEx | English (PDF, 1.1 MB) Spanish (PDF, 1.9 MB) |
English (PDF, 1.1 MB) |
Infertility English (PDF, 996.7 KB) Spanish (PDF, 1.7 MB) |
| Silver Full PPO 2000/60 OffEx | English (PDF, 1.1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 996.7 KB) Spanish (PDF, 1.7 MB) |
| Silver Tandem PPO 2000/60 OffEx | English (PDF, 1.1 MB) Spanish (PDF, 1.9 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 996.7 KB) Spanish (PDF, 1.7 MB) |
| Silver Full PPO 2350/65 OffEx | English (PDF, 1.1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 996.7 KB) Spanish (PDF, 1.7 MB) |
| Silver Tandem PPO 2350/65 OffEx | English (PDF, 1.1 MB) Spanish (PDF, 1.9 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 996.7 KB) Spanish (PDF, 1.7 MB) |
| Silver Full PPO 2550/70 OffEx | English (PDF, 1.1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 996.7 KB) Spanish (PDF, 1.7 MB) |
| Silver Tandem PPO 2550/70 OffEx | English (PDF, 1.1 MB) Spanish (PDF, 1.9 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 996.7 KB) Spanish (PDF, 1.7 MB) |
| Bronze Full PPO 5500/65 OffEx | English (PDF, 1.1 MB) Spanish (PDF, 1.9 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 996.7 KB) Spanish (PDF, 1.7 MB) |
| Bronze Tandem PPO 5500/65 OffEx | English (PDF, 1.1 MB) Spanish (PDF, 1.9 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 996.7 KB) Spanish (PDF, 1.7 MB) |
| Bronze Full PPO 6250/65 OffEx | English (PDF, 1.1 MB) Spanish (PDF, 1.9 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 996.7 KB) Spanish (PDF, 1.7 MB) |
| Bronze Tandem PPO 6250/65 OffEx | English (PDF, 1.1 MB) Spanish (PDF, 1.9 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 996.7 KB) Spanish (PDF, 1.7 MB) |
| Bronze Full PPO 6500/70 OffEx | English (PDF, 1.1 MB) Spanish (PDF, 1.9 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7 MB) |
| Bronze Tandem PPO 6500/70 OffEx | English (PDF, 1.1 MB) Spanish (PDF, 1.9 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 996.7 KB) Spanish (PDF, 1.7 MB) |
| Bronze Full PPO 7500/65 OffEx | English (PDF, 1.1 MB) Spanish (PDF, 1.9MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 996.7 KB) Spanish (PDF, 1.7 MB) |
| Bronze Tandem PPO 7500/65 OffEx | English (PDF, 1.1 MB) Spanish (PDF, 1.9 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 996.7 KB) Spanish (PDF, 1.7 MB) |
| Bronze Full PPO 6850/55 OffEx | English (PDF, 1.1 MB) Spanish (PDF, 1.9 MB) |
English (PDF, 1.1 MB) | IInfertility English (PDF, 996.7 KB) Spanish (PDF, 1.7 MB) |
| Bronze Tandem PPO 6850/55 OffEx | English (PDF, 1.1 MB) Spanish (PDF, 1.9 MB) |
English (PDF, 1.1 MB) |
Infertility English (PDF, 996.7 KB) Spanish (PDF, 1.7 MB) |
| Virtual Blue Plans | Summary of Benefits | Disclosures | Optional Benefit |
|---|---|---|---|
| Virtual Blue℠ Gold Tandem PPO 1500/45 OffEx | English (PDF, 275 KB) Spanish (PDF, 344 KB) |
English (PDF, 310 KB) |
Infertility English (PDF, 996.7 KB) Spanish (PDF, 1.7 MB) |
| Virtual Blue℠ Bronze Tandem PPO 7500/75 OffEx | English (PDF, 288 KB) Spanish (PDF, 353 KB) |
English (PDF, 310 KB) |
Infertility English (PDF, 996.7 KB) Spanish (PDF, 1.7 MB) |
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 + Child Dental |
English (PDF, 1.1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility English (PDF, 1.0 MB) Spanish (PDF, 1.7 MB) |
| Blue Shield Gold 80 PPO 350/25 + Child Dental |
English (PDF, 1.1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility English (PDF, 1.0 MB) Spanish (PDF, 1.7 MB) |
| Blue Shield Silver 70 PPO 2500/50 + Child Dental |
English (PDF, 1.1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility English (PDF, 1.0 MB) Spanish (PDF, 1.7 MB) |
| Blue Shield Bronze 60 PPO 6300/65 + Child Dental |
English (PDF, 1.1 MB) Spanish (PDF, 1.9 MB) |
English (PDF, 1.1 MB) |
Infertility English (PDF, 1.0 MB) Spanish (PDF, 1.7 MB) |
| Blue Shield Bronze Full PPO Savings 7000 + Child Dental | English (PDF, 257 KB) Spanish (PDF, 330 KB) |
English (PDF, 340 KB) |
Infertility English (PDF, 1.0 MB) Spanish (PDF, 1.7 MB) |
| Blue Shield Silver Full PPO Savings 2300/25% + Child Dental | English (PDF, 267 KB) Spanish (PDF, 331 KB) |
English (PDF, 340 KB) |
Infertility English (PDF, 1.0 MB) Spanish (PDF, 1.7 MB) |
Off-Exchange Package for Small Business — HSA/HDHP
| 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 English (PDF, 996.6 KB) Spanish (PDF, 1.7 MB) |
| Gold Tandem PPO Savings 1750/15% HDHP PrevRx OffEx | English (PDF, 1 MB) Spanish (PDF, 1.9 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 996.6 KB) Spanish (PDF, 1.7 MB) |
| Silver Full PPO Savings 2300/25% OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility English (PDF, 996.6 KB) Spanish (PDF, 1.7 MB) |
| Silver Tandem PPO Savings 2300/25% OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility English (PDF, 996.6 KB) Spanish (PDF, 1.7 MB) |
| Silver Full PPO Savings 2600/35% HDHP PrevRx OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility English (PDF, 996.6 KB) Spanish (PDF, 1.7 MB) |
| Silver Tandem PPO Savings 2600/35% HDHP PrevRx OffEx | English (PDF, 1 MB) Spanish (PDF, 1.9 MB) |
English (PDF, 1.1 MB) |
Infertility English (PDF, 996.6 KB) Spanish (PDF, 1.7 MB) |
| Bronze Full PPO Savings 5700/40% OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility English (PDF, 996.6 KB) Spanish (PDF, 1.7 MB) |
| Bronze Tandem PPO Savings 5700/40% OffEx | English (PDF, 1MB) Spanish (PDF, 1.9MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 996.6 KB) Spanish (PDF, 1.7 MB) |
| Bronze Full PPO Savings 7000 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility English (PDF, 996.6 KB) Spanish (PDF, 1.7 MB) |
| Bronze Tandem PPO Savings 7000 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) |
Infertility English (PDF, 996.6 KB) Spanish (PDF, 1.7 MB) |
