Summary of Benefits 2027

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, 295 KB) Spanish (PDF, 311 KB)	English (PDF, 497 KB)	Infertility English (PDF, 203 KB) Spanish (PDF, 211 KB)
Platinum Local Access+ HMO® 0/20 OffEx	English (PDF, 295 KB) Spanish (PDF, 311 KB)	English (PDF, 497 KB)	Infertility English (PDF, 203 KB) Spanish (PDF, 211 KB)
Platinum Trio HMO 0/20 OffEx	English (PDF, 294 KB) Spanish (PDF, 311 KB)	English (PDF, 497 KB)	Infertility English (PDF, 203 KB) Spanish (PDF, 211 KB)
Platinum Access+ HMO® 0/25 OffEx	English (PDF, 295 KB) Spanish (PDF, 311 KB)	English (PDF, 497 KB)	Infertility English (PDF, 203 KB) Spanish (PDF, 211 KB)
Platinum Local Access+ HMO® 0/25 OffEx	English (PDF, 295 KB) Spanish (PDF, 311 KB)	English (PDF, 497 KB)	Infertility English (PDF, 203 KB) Spanish (PDF, 211 KB)
Platinum Trio HMO 0/25 OffEx	English (PDF, 295 KB) Spanish (PDF, 311 KB)	English (PDF, 497 KB)	Infertility English (PDF, 203 KB) Spanish (PDF, 211 KB)
Platinum Access+ HMO® 0/30 OffEx	English (PDF, 295 KB) Spanish (PDF, 311 KB)	English (PDF, 497 KB)	Infertility English (PDF, 203KB) Spanish (PDF, 211 KB)
Platinum Local Access+ HMO® 0/30 OffEx	English (PDF, 295 KB) Spanish (PDF, 311 KB)	English (PDF, 497 KB)	Infertility English (PDF, 203 KB) Spanish (PDF, 211KB)
Platinum Trio HMO 0/30 OffEx	English (PDF, 294 KB) Spanish (PDF, 311 KB)	English (PDF, 497 KB)	Infertility English (PDF, 203 KB) Spanish (PDF, 211 KB)
Gold Access+ HMO® 0/35 OffEx	English (PDF, 295 KB) Spanish (PDF, 311 KB)	English (PDF, 497 KB)	Infertility English (PDF, 203 KB) Spanish (PDF, 211 KB)
Gold Local Access+ HMO® 0/35 OffEx	English (PDF, 295 KB) Spanish (PDF, 311 KB)	English (PDF, 497 KB)	Infertility English (PDF, 203 KB) Spanish (PDF, 211 KB)
Gold Trio HMO 0/35 OffEx	English (PDF, 295 KB) Spanish (PDF, 311 KB)	English (PDF, 497 KB)	Infertility English (PDF, 203 KB) Spanish (PDF, 211 KB)
Gold Access+ HMO® 500/35 OffEx	English (PDF, 297 KB) Spanish (PDF, 315 KB)	English (PDF, 497 KB)	Infertility English (PDF, 203 KB) Spanish (PDF, 211 KB)
Gold Local Access+ HMO® 500/35 OffEx	English (PDF, 297 KB) Spanish (PDF, 315 KB)	English (PDF, 497 KB)	Infertility English (PDF, 203 KB) Spanish (PDF, 211 KB)
Gold Trio HMO 500/35 OffEx	English (PDF, 297 KB) Spanish (PDF, 315 KB)	English (PDF, 497 KB)	Infertility English (PDF, 203 KB) Spanish (PDF, 211 KB)
Gold Access+ HMO® 1000/35 OffEx	English (PDF, 297 KB) Spanish (PDF, 315 KB)	English (PDF, 497 KB)	Infertility English (PDF, 203 KB) Spanish (PDF, 211 KB)
Gold Local Access+ HMO® 1000/35 OffEx	English (PDF, 297 KB) Spanish (PDF, 315 KB)	English (PDF, 497 KB)	Infertility English (PDF, 203 KB) Spanish (PDF, 211 KB)
Gold Trio HMO 1000/35 OffEx	English (PDF, 296 KB) Spanish (PDF, 315 KB)	English (PDF, 497 KB)	Infertility English (PDF, 203KB) Spanish (PDF, 211 KB)
Gold Access+ HMO® 1500/35 OffEx	English (PDF, 297 KB) Spanish (PDF, 315 KB)	English (PDF, 497 KB)	Infertility English (PDF, 203 KB) Spanish (PDF, 211 KB)
Gold Local Access+ HMO® 1500/35 OffEx	English (PDF, 297 KB) Spanish (PDF, 315 KB)	English (PDF, 497 KB)	Infertility English (PDF, 203 KB) Spanish (PDF, 211 KB)
Gold Trio HMO 1500/35 OffEx	English (PDF, 296 KB) Spanish (PDF, 315 KB)	English (PDF, 497 KB)	Infertility English (PDF, 203 KB) Spanish (PDF, 211 KB)
Silver Access+ HMO® 2100/70 OffEx	English (PDF, 297 KB) Spanish (PDF, 316 KB)	English (PDF, 497 KB)	Infertility English (PDF, 203 KB) Spanish (PDF, 211 KB)
Silver Access+ HMO® 2850/70 OffEx	English (PDF, 297 KB) Spanish (PDF, 315 KB)	English (PDF, 497 KB)	Infertility English (PDF, 203 KB) Spanish (PDF, 211 KB)
Silver Local Access+ HMO® 2100/70 OffEx	English (PDF, 297 KB) Spanish (PDF, 316 KB)	English (PDF, 497 KB)	Infertility English (PDF, 203 KB) Spanish (PDF, 211 KB)
Silver Local Access+ HMO® 2850/70 OffEx	English (PDF, 297 KB) Spanish (PDF, 316 KB)	English (PDF, 497 KB)	Infertility English (PDF, 203 KB) Spanish (PDF, 211 KB)
Silver Trio HMO 2100/70 OffEx	English (PDF, 297 KB) Spanish (PDF, 316 KB)	English (PDF, 497 KB)	Infertility English (PDF, 203 KB) Spanish (PDF, 211 KB)
Silver Trio HMO 2850/70 OffEx	English (PDF, 296 KB) Spanish (PDF, 315 KB)	English (PDF, 497 KB)	Infertility English (PDF, 203 KB) Spanish (PDF, 211 KB)
Bronze Access+ HMO® 7000/65 OffEx	English (PDF, 297 KB) Spanish (PDF, 315 KB)	English (PDF, 497 KB)	Infertility English (PDF, 203 KB) Spanish (PDF, 211 KB)
Bronze Local Access+ HMO® 7000/65 OffEx	English (PDF, 297 KB) Spanish (PDF, 315 KB)	English (PDF, 497 KB)	Infertility English (PDF, 203 KB) Spanish (PDF, 211 KB)
Bronze Trio HMO 7000/65 OffEx	English (PDF, 296 KB) Spanish (PDF, 315 KB)	English (PDF, 497 KB)	Infertility English (PDF, 203 KB) Spanish (PDF, 211 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 0/25 PCP + Child Dental	English (PDF, 294 KB) Spanish (PDF, 310 KB)	English (PDF, 497 KB)	Infertility English (PDF, 203 KB) Spanish (PDF, 211 KB)
Blue Shield Trio Gold 80 HMO 325/40 PCP + Child Dental	English (PDF, 295 KB) Spanish (PDF, 313 KB)	English (PDF, 497 KB)	Infertility English (PDF, 203 KB) Spanish (PDF, 212 KB)
Blue Shield Trio Silver 70 HMO 2500/60 PCP + Child Dental	English (PDF, 295 KB) Spanish (PDF, 314 KB)	English (PDF, 497 KB)	Infertility English (PDF, 203 KB) Spanish (PDF, 211 KB)
Blue Shield Access+ Gold 80 HMO® 325/40 PCP + Child Dental	English (PDF, 227 KB) Spanish (PDF, 314 KB)	English (PDF, 497 KB)	Infertility English (PDF, 203 KB) Spanish (PDF, 212 KB)
Blue Shield Access+ Platinum 90 HMO® 0/25 PCP + Child Dental	English (PDF, 295 KB) Spanish (PDF, 311 KB)	English (PDF, 497 KB)	Infertility English (PDF, 203 KB) Spanish (PDF, 211 KB)
Blue Shield Access+ Silver 70 HMO® 2500/60 PCP + Child Dental	English (PDF, 296 KB) Spanish (PDF, 315 KB)	English (PDF, 497 KB)	Infertility English (PDF, 203 KB) Spanish (PDF,211 KB)
Blue Shield Trio Bronze 60 HMO 7000/65 PCP + Child Dental Alt	English (PDF, 296 KB) Spanish (PDF, 315 KB)	English (PDF, 497 KB)	Infertility English (PDF, 203 KB) Spanish (PDF, 211 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, 332 KB) Spanish (PDF, 368 KB)	English (PDF, 497 KB)	Infertility English (PDF, 212 KB) Spanish (PDF, 218 KB)
Platinum Tandem PPO 0/0 OffEx	English (PDF, 332 KB) Spanish (PDF, 368 KB)	English (PDF, 497 KB)	Infertility English (PDF, 212 KB) Spanish (PDF, 218 KB)
Platinum Full PPO 0/10 OffEx	English (PDF, 332 KB) Spanish (PDF, 368 KB)	English (PDF, 497 KBB)	Infertility English (PDF, 212 KB) Spanish (PDF, 218 KB)
Platinum Tandem PPO 0/10 OffEx	English (PDF, 332 KB) Spanish (PDF, 368 KB)	English (PDF, 497 KB)	Infertility English (PDF, 212 KB) Spanish (PDF, 218 KB)
Platinum Full PPO 250/10 OffEx	English (PDF, 333 KB) Spanish (PDF, 369 KB)	English (PDF, 497 KB)	Infertility English (PDF, 212 KB) Spanish (PDF, 218 KB)
Platinum Tandem PPO 250/10 OffEx	English (PDF, 333 KB) Spanish (PDF, 369 KB)	English (PDF, 497 KB)	Infertility English (PDF, 212 KB) Spanish (PDF, 218 KB)
Platinum Full PPO 250/15 OffEx	English (PDF, 334 KB) Spanish (PDF, 371 KB)	English (PDF, 497 KB)	Infertility English (PDF, 212 KB) Spanish (PDF, 218 KB)
Platinum Tandem PPO 250/15 OffEx	English (PDF, 334 KB) Spanish (PDF, 371 KB)	English (PDF, 497 KB)	Infertility English (PDF, 212 KB) Spanish (PDF, 218 KB)
Gold Full PPO 0/35 OffEx	English (PDF, 334 KB) Spanish (PDF, 371 KB)	English (PDF, 497 KB)	Infertility English (PDF, 212 KB) Spanish (PDF, 218 KB)
Gold Tandem PPO 0/35 OffEx	English (PDF, 334 KB) Spanish (PDF, 371 KB)	English (PDF, 497 KB)	Infertility English (PDF, 212 KB) Spanish (PDF, 218 KB)
Gold Full PPO 500/30 OffEx	English (PDF, 335 KB) Spanish (PDF, 372 KB)	English (PDF, 497 KB)	Infertility English (PDF, 212 KB) Spanish (PDF, 218 KB)
Gold Tandem PPO 500/30 OffEx	English (PDF, 335 KB) Spanish (PDF, 372 KB)	English (PDF, 497 KB)	Infertility English (PDF, 212 KB) Spanish (PDF, 218 KB)
Gold Full PPO 750/35 OffEx	English (PDF, 335 KB) Spanish (PDF, 372 KB)	English (PDF, 497 KB)	Infertility English (PDF, 212 KB) Spanish (PDF, 218 KB)
Gold Tandem PPO 750/35 OffEx	English (PDF, 335 KB) Spanish (PDF, 372 KB)	English (PDF, 497 KB)	Infertility English (PDF, 212 KB) Spanish (PDF, 218 KB)
Gold Full PPO 1000/30 OffEx	English (PDF, 335 KB) Spanish (PDF, 372 KB)	English (PDF, 497 KB)	Infertility English (PDF, 212 KB) Spanish (PDF, 218 KB)
Gold Tandem PPO 1000/30 OffEx	English (PDF, 335 KB) Spanish (PDF, 372 KB)	English (PDF, 497 KB)	Infertility English (PDF, 212 KB) Spanish (PDF, 218 KB)
Silver Full PPO 1800/65 OffEx	English (PDF, 335 KB) Spanish (PDF, 372 KB)	English (PDF, 497 KB)	Infertility English (PDF, 212 KB) Spanish (PDF, 218 KB)
Silver Tandem PPO 1800/65 OffEx	English (PDF, 335 KB) Spanish (PDF, 372 KB)	English (PDF, 497 KB)	Infertility English (PDF, 212 KB) Spanish (PDF, 218 KB)
Silver Full PPO 2100/75 OffEx	English (PDF, 335 KB) Spanish (PDF, 373 KB)	English (PDF, 497 KB)	Infertility English (PDF, 212 KB) Spanish (PDF, 218 KB)
Silver Tandem PPO 2100/75 OffEx	English (PDF, 335 KB) Spanish (PDF, 373 KB)	English (PDF, 497 KB)	Infertility English (PDF, 212 KB) Spanish (PDF, 218 KB)
Silver Full PPO 2550/75 OffEx	English (PDF, 335 KB) Spanish (PDF, 372 KB)	English (PDF, 497 KB)	Infertility English (PDF, 212 KB) Spanish (PDF, 218 KB)
Silver Tandem PPO 2550/75 OffEx	English (PDF, 335 KB) Spanish (PDF, 372 KB)	English (PDF, 497 KB)	Infertility English (PDF, 212 KB) Spanish (PDF, 218 KB)
Bronze Full PPO 4500/65 OffEx	English (PDF, 347 KB) Spanish (PDF, 380 KB)	English (PDF, 497 KB)	Infertility English (PDF, 212 KB) Spanish (PDF, 218 KB)
Bronze Tandem PPO 4500/65 OffEx	English (PDF, 335 KB) Spanish (PDF, 380 KB)	English (PDF, 497 KB)	Infertility English (PDF, 212 KB) Spanish (PDF, 218 KB)
Bronze Full PPO 6250/65 OffEx	English (PDF, 347 KB) Spanish (PDF, 379 KB)	English (PDF, 497 KB)	Infertility English (PDF, 212 KB) Spanish (PDF, 218 KB)
Bronze Tandem PPO 6250/65 OffEx	English (PDF, 347 KB) Spanish (PDF, 379 KB)	English (PDF, 497 KB)	Infertility English (PDF, 212 KB) Spanish (PDF, 218 KB)
Bronze Full PPO 6500/70 OffEx	English (PDF, 347 KB) Spanish (PDF, 380 KB)	English (PDF, 497 KB)	Infertility English (PDF, 212 KB) Spanish (PDF, 218 KB)
Bronze Tandem PPO 6500/70 OffEx	English (PDF, 347 KB) Spanish (PDF, 380 KB)	English (PDF, 497 KB)	Infertility English (PDF, 212 KB) Spanish (PDF, 218 KB)
Bronze Full PPO 7500/65 OffEx	English (PDF, 346 KB) Spanish (PDF, 379 KB)	English (PDF, 497 KB)	Infertility English (PDF, 212 KB) Spanish (PDF, 218 KB)
Bronze Tandem PPO 7500/65 OffEx	English (PDF, 347 KB) Spanish (PDF, 379 KB)	English (PDF, 497 KB)	Infertility English (PDF, 212 KB) Spanish (PDF, 218 KB)
Bronze Full PPO 6850/55 OffEx	English (PDF, 347 KB) Spanish (PDF, 380 KB)	English (PDF, 497 KB)	Infertility English (PDF, 212 KB) Spanish (PDF, 218 KB)
Bronze Tandem PPO 6850/55 OffEx	English (PDF, 347 KB) Spanish (PDF, 380 KB)	English (PDF, 497 KB)	Infertility English (PDF, 212 KB) Spanish (PDF, 218 KB)

218

Mirror package for Small Business – PPO plans

Blue Shield Mirror PPO Plans	Summary of Benefits	Disclosures	Optional Benefit
Blue Shield Platinum 90 PPO 0/25 PCP + Child Dental	English (PDF, 330 KB) Spanish (PDF, 367 KB)	English (PDF, 497 KB)	Infertility English (PDF, 212 KB) Spanish (PDF, 218 KB)
Blue Shield Gold 80 PPO 500/30 PCP + Child Dental	English (PDF, 332 KB) Spanish (PDF, 369 KB)	English (PDF, 497 KB)	Infertility English (PDF, 212 KB) Spanish (PDF, 218 KB)
Blue Shield Silver 70 PPO 2500/60 PCP + Child Dental	English (PDF, 333 KB) Spanish (PDF, 370 KB)	English (PDF, 497 KB)	Infertility English (PDF, 212 KB) Spanish (PDF, 218 KB)
Blue Shield Bronze 60 PPO 5800/60 PCP + Child Dental	English (PDF, 345 KB) Spanish (PDF, 377 KB)	English (PDF, 497 KB)	Infertility English (PDF, 212 KB) Spanish (PDF, 218 KB)
Blue Shield Bronze 60 HDHP PPO 7850/0% PCP + Child Dental Alt	English (PDF, 333 KB) Spanish (PDF, 369 KB)	English (PDF, 497 KB)	Infertility English (PDF, 212 KB) Spanish (PDF, 218 KB)
Blue Shield Silver 70 HDHP PPO 2450/30% PCP + Child Dental Alt	English (PDF, 333 KB) Spanish (PDF, 372 KB)	English (PDF, 497 KB)	Infertility English (PDF, 212 KB) Spanish (PDF, 218 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 1900/15% HDHP PrevRx OffEx	English (PDF, 334 KB) Spanish (PDF, 371 KB)	English (PDF, 497 KB)	Infertility English (PDF, 212 KB) Spanish (PDF, 218 KB)
Gold Tandem PPO Savings 1900/15% HDHP PrevRx OffEx	English (PDF, 334 KB) Spanish (PDF, 371 KB)	English (PDF, 497 KB)	Infertility English (PDF, 212 KB) Spanish (PDF, 218 KB)
Silver Full PPO Savings 2450/30% OffEx	English (PDF, 333 KB) Spanish (PDF, 371 KB)	English (PDF, 497 KB)	Infertility English (PDF, 212 KB) Spanish (PDF, 217 KB)
Silver Tandem PPO Savings 2450/30% OffEx	English (PDF, 333 KB) Spanish (PDF, 371 KB)	English (PDF, 497 KB)	Infertility English (PDF, 212 KB) Spanish (PDF, 217 KB)
Silver Full PPO Savings 2950/35% HDHP PrevRx OffEx	English (PDF, 334 KB) Spanish (PDF, 372 KB)	English (PDF, 497 KB)	Infertility English (PDF, 212 KB) Spanish (PDF, 218 KB)
Silver Tandem PPO Savings 2950/35% HDHP PrevRx OffEx	English (PDF, 334 KB) Spanish (PDF, 372 KB)	English (PDF, 497 KB)	Infertility English (PDF, 212 KB) Spanish (PDF, 218 KB)
Bronze Full PPO Savings 6000/40% OffEx	English (PDF, 332 KB) Spanish (PDF, 371 KB)	English (PDF, 497 KB)	Infertility English (PDF, 212 KB) Spanish (PDF, 218 KB)
Bronze Tandem PPO Savings 6000/40% OffEx	English (PDF, 333 KB) Spanish (PDF, 371 KB)	English (PDF, 497 KB)	Infertility English (PDF, 212 KB) Spanish (PDF, 218 KB)
Bronze Full PPO Savings 7850 OffEx	English (PDF, 332 KB) Spanish (PDF, 367 KB)	English (PDF, 497 KB)	Infertility English (PDF, 212 KB) Spanish (PDF, 218 KB)
Bronze Tandem PPO Savings 7850 OffEx	English (PDF, 332 KB) Spanish (PDF, 367 KB)	English (PDF, 497 KB)	Infertility English (PDF, 212 KB) Spanish (PDF, 218 KB)

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.