Summary of Benefits

Broker Resources

For 2022 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). Click here for FAQs about the SOBs.

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, 2022, 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® 2000/60 OffEx	English (PDF, 1MB) Spanish (PDF, 1.8MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.9KB) Spanish (PDF, 1.7MB)
Silver Access+ HMO® 2750/65 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® 2000/60 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® 2750/65 OffEx	English (PDF, 1MB) Spanish (PDF, 1.8MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.9KB) Spanish (PDF, 1.7MB)
Silver Trio HMO 2000/60 OffEx	English (PDF, 1MB) Spanish (PDF, 1.8MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.9KB) Spanish (PDF, 1.7MB)
Silver Trio HMO 2750/65 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, 1MB) Spanish (PDF, 1.8MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.9KB) Spanish (PDF, 1.7MB)
Blue Shield Trio Gold 80 HMO 250/35 + Child Dental	English (PDF, 1MB) Spanish (PDF, 1.8MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.9KB) Spanish (PDF, 1.7MB)
Blue Shield Trio Silver 70 HMO 2250/55 + Child Dental	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 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 1800/45 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 1800/45 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 2225/50 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 2225/50 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 2400/55 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 2400/55 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)

Blue Shield Mirror PPO Plans	Summary of Benefits	Disclosures	Optional Benefit
Blue Shield Platinum 90 PPO 0/15 + Child Dental	English (PDF, 1.1MB) Spanish (PDF, 1.8MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB)
Blue Shield Gold 80 PPO 350/25 + Child Dental	English (PDF, 1.1MB) Spanish (PDF, 1.8MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB)
Blue Shield Silver 70 PPO 2250/50 + Child Dental	English (PDF, 1.1MB) Spanish (PDF, 1.8MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB)
Blue Shield Bronze 60 PPO 6300/65 + Child Dental	English (PDF, 1.1MB) Spanish (PDF, 1.9MB)	English (PDF, 1.1MB)	Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB)

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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 2100/25% 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 2100/25% 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)