Summary of Benefits

Broker Resources

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, 1.04MB).

In addition to the SOBs, the Summary of Benefits and Coverage (SBC) Forms provide your clients with an easy-to-understand overview of what our plans for groups of 1 to 100 cover. Click here to download SBC forms and other resources.

These SOBs are effective January 1, 2023, for small businesses of 1 to 100.

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Blue Shield Off-Exchange HMO Plans	Summary of Benefits	Disclosures	Optional Benefit
Platinum Access+ HMO® 0/20 OffEx	English (PDF, 1MB) Spanish (PDF, 1.8MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.9KB) Spanish (PDF, 1.7MB)
Platinum Local Access+ HMO® 0/20 OffEx	English (PDF, 1MB) Spanish (PDF, 1.8MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.9KB) Spanish (PDF, 1.7MB)
Platinum Trio HMO 0/20 OffEx	English (PDF, 1MB) Spanish (PDF, 1.8MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.9KB) Spanish (PDF, 1.7MB)
Platinum Access+ HMO® 0/25 OffEx	English (PDF, 1MB) Spanish (PDF, 1.8MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.9KB) Spanish (PDF, 1.7MB)
Platinum Local Access+ HMO® 0/25 OffEx	English (PDF, 1MB) Spanish (PDF, 1.8MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.9KB) Spanish (PDF, 1.7MB)
Platinum Trio HMO 0/25 OffEx	English (PDF, 1MB) Spanish (PDF, 1.8MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.9KB) Spanish (PDF, 1.7MB)
Platinum Access+ HMO® 0/30 OffEx	English (PDF, 1MB) Spanish (PDF, 1.8MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.9KB) Spanish (PDF, 1.7MB)
Platinum Local Access+ HMO® 0/30 OffEx	English (PDF, 1MB) Spanish (PDF, 1.8MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.9KB) Spanish (PDF, 1.7MB)
Platinum Trio HMO 0/30 OffEx	English (PDF, 1MB) Spanish (PDF, 1.8MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.9KB) Spanish (PDF, 1.7MB)
Gold Access+ HMO® 0/30 OffEx	English (PDF, 1MB) Spanish (PDF, 1.8MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.9KB) Spanish (PDF, 1.7MB)
Gold Local Access+ HMO® 0/30 OffEx	English (PDF, 1MB) Spanish (PDF, 1.8MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.9KB) Spanish (PDF, 1.7MB)
Gold Trio HMO 0/30 OffEx	English (PDF, 1MB) Spanish (PDF, 1.8MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.9KB) Spanish (PDF, 1.7MB)
Gold Access+ HMO® 500/35 OffEx	English (PDF, 1MB) Spanish (PDF, 1.8MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.9KB) Spanish (PDF, 1.7MB)
Gold Local Access+ HMO® 500/35 OffEx	English (PDF, 1MB) Spanish (PDF, 1.8MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.9KB) Spanish (PDF, 1.7MB)
Gold Trio HMO 500/35 OffEx	English (PDF, iMB) Spanish (PDF, 1.8MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.9KB) Spanish (PDF, 1.7MB)
Gold Access+ HMO® 1000/35 OffEx	English (PDF, 1MB) Spanish (PDF, 1.8MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.9KB) Spanish (PDF, 1.7MB)
Gold Local Access+ HMO® 1000/35 OffEx	English (PDF, 1MB) Spanish (PDF, 1.8MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.9KB) Spanish (PDF, 1.7MB)
Gold Trio HMO 1000/35 OffEx	English (PDF, 1MB) Spanish (PDF, 1.8MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.9KB) Spanish (PDF, 1.7MB)
Gold Access+ HMO® 1500/35 OffEx	English (PDF, 1MB) Spanish (PDF, 1.8MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.9KB) Spanish (PDF, 1.7MB)
Gold Local Access+ HMO® 1500/35 OffEx	English (PDF, 1MB) Spanish (PDF, 1.8MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.9KB) Spanish (PDF, 1.7MB)
Gold Trio HMO 1500/35 OffEx	English (PDF, 49KB) Spanish (PDF, 49KB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.9KB) Spanish (PDF, 1.7MB)
Silver Access+ HMO® 2300/70 OffEx	English (PDF, 1MB) Spanish (PDF, 1.8MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.9KB) Spanish (PDF, 1.7MB)
Silver Access+ HMO® 2750/70 OffEx	English (PDF, 1MB) Spanish (PDF, 1.8MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.9KB) Spanish (PDF, 1.7MB)
Silver Local Access+ HMO® 2300/70 OffEx	English (PDF, 1MB) Spanish (PDF, 1.8MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.9KB) Spanish (PDF, 1.7MB)
Silver Local Access+ HMO® 2750/70 OffEx	English (PDF, 1MB) Spanish (PDF, 1.8MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.9KB) Spanish (PDF, 1.7MB)
Silver Trio HMO 2300/70 OffEx	English (PDF, 1MB) Spanish (PDF, 1.8MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.9KB) Spanish (PDF, 1.7MB)
Silver Trio HMO 2750/70 OffEx	English (PDF, 1MB) Spanish (PDF, 1.8MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.9KB) Spanish (PDF, 1.7MB)
Bronze Access+ HMO® 7000/70 OffEx	English (PDF, 1MB) Spanish (PDF, 1.8MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.9KB) Spanish (PDF, 1.7MB)
Bronze Local Access+ HMO 7000/70 OffEx	English (PDF, 1MB) Spanish (PDF, 1.8MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.9KB) Spanish (PDF, 1.7MB)
Bronze Trio HMO 7000/70 OffEx	English (PDF, 1MB) Spanish (PDF, 1.8MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.9KB) Spanish (PDF, 1.7MB)

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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, 311 KB)	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, 311 KB)	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, 311 KB)	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, 311 KB)	Infertility English (PDF, 1.0 MB) Spanish (PDF, 1.7 MB)

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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 English (PDF, 996.7KB) Spanish (PDF, 1.7MB)
Platinum Tandem PPO 0/0 OffEx	English (PDF, 1.1MB) Spanish (PDF, 1.8MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB)
Platinum Full PPO 0/10 OffEx	English (PDF, 1.1MB) Spanish (PDF, 1.8MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB)
Platinum Tandem PPO 0/10 OffEx	English (PDF, 1.1MB) Spanish (PDF, 1.8MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB)
Platinum Full PPO 250/10 OffEx	English (PDF, 1.1MB) Spanish (PDF, 1.8MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB)
Platinum Tandem PPO 250/10 OffEx	English (PDF, 1.1MB) Spanish (PDF, 1.8MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB)
Platinum Full PPO 250/15 OffEx	English (PDF, 1.1MB) Spanish (PDF, 1.8MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB)
Platinum Tandem PPO 250/15 OffEx	English (PDF, 1.1MB) Spanish (PDF, 1.9MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB)
Gold Full PPO 0/25 OffEx	English (PDF, 1.1MB) Spanish (PDF, 1.8MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB)
Gold Tandem PPO 0/25 OffEx	English (PDF, 1.1MB) Spanish (PDF, 1.8MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB)
Gold Full PPO 500/30 OffEx	English (PDF, 1.1MB) Spanish (PDF, 1.8MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB)
Gold Tandem PPO 500/30 OffEx	English (PDF, 1.1MB) Spanish (PDF, 1.9MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB)
Gold Full PPO 750/30 OffEx	English (PDF, 1.1MB) Spanish (PDF, 1.8MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB)
Gold Tandem PPO 750/30 OffEx	English (PDF, 1.1MB) Spanish (PDF, 1.9MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB)
Gold Full PPO 1000/35 OffEx	English (PDF, 1.1MB) Spanish (PDF, 1.8MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB)
Gold Tandem PPO 1000/35 OffEx	English (PDF, 1.1MB) Spanish (PDF, 1.9MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB)
Silver Full PPO 2000/60 OffEx	English (PDF, 1.1MB) Spanish (PDF, 1.8MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB)
Silver Tandem PPO 2000/60 OffEx	English (PDF, 1.1MB) Spanish (PDF, 1.9MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB)
Silver Full PPO 2350/65 OffEx	English (PDF, 1.1MB) Spanish (PDF, 1.8MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB)
Silver Tandem PPO 2350/65 OffEx	English (PDF, 1.1MB) Spanish (PDF, 1.9MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB)
Silver Full PPO 2550/70 OffEx	English (PDF, 1.1MB) Spanish (PDF, 1.8MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB)
Silver Tandem PPO 2550/70 OffEx	English (PDF, 1.1MB) Spanish (PDF, 1.9MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB)
Bronze Full PPO 5500/65 OffEx	English (PDF, 1.1MB) Spanish (PDF, 1.9MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB)
Bronze Tandem PPO 5500/65 OffEx	English (PDF, 1.1MB) Spanish (PDF, 1.9MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB)
Bronze Full PPO 6250/65 OffEx	English (PDF, 1.1MB) Spanish (PDF, 1.9MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB)
Bronze Tandem PPO 6250/65 OffEx	English (PDF, 1.1MB) Spanish (PDF, 1.9MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB)
Bronze Full PPO 6500/70 OffEx	English (PDF, 1.1MB) Spanish (PDF, 1.9MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB)
Bronze Tandem PPO 6500/70 OffEx	English (PDF, 1.1MB) Spanish (PDF, 1.9MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB)
Bronze Full PPO 7500/65 OffEx	English (PDF, 1.1MB) Spanish (PDF, 1.9MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB)
Bronze Tandem PPO 7500/65 OffEx	English (PDF, 1.1MB) Spanish (PDF, 1.9MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB)
Bronze Full PPO 6850/55 OffEx	English (PDF, 1.1MB) Spanish (PDF, 1.9MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB)
Bronze Tandem PPO 6850/55 OffEx	English (PDF, 1.1MB) Spanish (PDF, 1.9MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB)

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 English (PDF, 996.7KB) Spanish (PDF, 1.7MB)
Virtual Blue℠ Bronze Tandem PPO 7500/75 OffEx	English (PDF, 288KB) Spanish (PDF, 353KB)	English (PDF, 310KB)	Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB)

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)

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Blue Shield Off-Exchange HSA HDHP Plans	Summary of Benefits	Disclosures	Optional Benefit
Gold Full PPO Savings 1750/15% HDHP PrevRx OffEx	English (PDF, 1MB) Spanish (PDF, 1.8MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.6KB) Spanish (PDF, 1.7MB)
Gold Tandem PPO Savings 1750/15% HDHP PrevRx OffEx	English (PDF, 1MB) Spanish (PDF, 1.9MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.6KB) Spanish (PDF, 1.7MB)
Silver Full PPO Savings 2300/25% OffEx	English (PDF, 1MB) Spanish (PDF, 1.8MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.6KB) Spanish (PDF, 1.7MB)
Silver Tandem PPO Savings 2300/25% OffEx	English (PDF, 1MB) Spanish (PDF, 1.8MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.6KB) Spanish (PDF, 1.7MB)
Silver Full PPO Savings 2600/35% HDHP PrevRx OffEx	English (PDF, 1MB) Spanish (PDF, 1.8MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.6KB) Spanish (PDF, 1.7MB)
Silver Tandem PPO Savings 2600/35% HDHP PrevRx OffEx	English (PDF, 1MB) Spanish (PDF, 1.9MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.6KB) Spanish (PDF, 1.7MB)
Bronze Full PPO Savings 5700/40% OffEx	English (PDF, 1MB) Spanish (PDF, 1.8MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.6KB) Spanish (PDF, 1.7MB)
Bronze Tandem PPO Savings 5700/40% OffEx	English (PDF, 1MB) Spanish (PDF, 1.9MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.6KB) Spanish (PDF, 1.7MB)
Bronze Full PPO Savings 7000 OffEx	English (PDF, 1MB) Spanish (PDF, 1.8MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.6KB) Spanish (PDF, 1.7MB)
Bronze Tandem PPO Savings 7000 OffEx	English (PDF, 1MB) Spanish (PDF, 1.8MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.6KB) Spanish (PDF, 1.7MB)