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 0/35 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 0/35 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) |
Virtual Blue℠ Platinum Tandem PPO 250/20 OffEx | English (PDF, 288KB) Spanish (PDF, 353KB) |
English (PDF, 310KB) |
Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB) |
Virtual Blue℠ Silver Tandem PPO 2700/75 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 2500/55 + 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 6300/60 + 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 60 HDHP PPO 7500/0% + Child Dental Alt | 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 70 HDHP PPO 2300/30% + Child Dental Alt | English (PDF, 267 KB) Spanish (PDF, 331 KB) |
English (PDF, 340 KB) |
Infertility English (PDF, 1.0 MB) Spanish (PDF, 1.7 MB) |
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, 1.1MB) |
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 2300/30% 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 2300/30% 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 7500 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 7500 OffEx | English (PDF, 1MB) Spanish (PDF, 1.8MB) |
English (PDF, 1.1MB) |
Infertility English (PDF, 996.6KB) Spanish (PDF, 1.7MB) |