2019 Summary of Benefits

2019 Summary of Benefits

2018 Benefit Summaries  |  Dental Benefit Summaries  |  Vision Benefit Summaries

 

The following Individual and Family Plan medical Summaries of Benefits (SOB) are effective January 1, 2019, and must be accompanied by the Important Legal Information booklet (PDF, 2.5MB), Spanish  (PDF, 2.1MB)

In addition to the Summary of Benefits, the Evidence of Coverage/Policy (EOC) and Summary of Benefits and Coverage (SBC) forms provide your clients with an easy-to-understand overview of what our IFP plans cover. Visit blueshieldca.com/policies to download the forms.

Trio HMO Plans Summary of Benefits
Blue Shield Platinum 90 Trio HMO English (PDF, 2MB)
Spanish (PDF, 2MB)
 
 
Blue Shield Gold 80 Trio HMO English (PDF, 2MB)
Spanish (PDF, 2MB)
 
 
Blue Shield Silver 70 Trio HMO English (PDF, 2MB)
Spanish (PDF, 2MB)
 
 
Silver 70 Off Exchange Trio HMO English (PDF, 2MB)
Spanish (PDF, 2MB)
 
 
PPO Plans Summary of Benefits
Blue Shield Platinum 90 PPO English (PDF, 2MB)
Spanish (PDF, 2MB)
 
 
Blue Shield Gold 80 PPO English (PDF, 2MB)
Spanish (PDF, 2MB)
 
 
Blue Shield Silver 70 PPO English (PDF, 2MB)
Spanish (PDF, 2MB)
 
 
Silver 70 Off Exchange PPO English (PDF, 2MB)
Spanish (PDF, 2MB)
 
 
Silver 1850 PPO English (PDF, 2MB)
Spanish (PDF, 2MB)
 
 
Blue Shield Bronze 60 PPO English (PDF, 2MB)
Spanish (PDF, 2MB)
 
 
Blue Shield Bronze 60 HDHP PPO English (PDF, 2MB)
Spanish (PDF, 2MB)
 
 
Blue Shield Minimum Coverage PPO English (PDF, 2MB)
Spanish (PDF, 2MB)
 

We offer six Silver cost-sharing reduction plans through Covered California for clients whose income is between 138% to 250% of the federal poverty level (FPL). These plans are available only through Covered California.

Cost-Sharing Reduction Plans Summary of Benefits
Blue Shield Silver 73 PPO English (PDF, 2MB)
Spanish (PDF, 2MB)
 
Blue Shield Silver 73 Trio HMO English (PDF, 2MB)
Spanish (PDF, 2MB)
 
 
Blue Shield Silver 87 PPO English (PDF, 2MB)
Spanish (PDF, 2MB)
 
Blue Shield Silver 87 Trio HMO English (PDF, 2MB)
Spanish (PDF, 2MB)
 
 
Blue Shield Silver 94 PPO English (PDF, 2MB)
Spanish (PDF, 2MB)
 
Blue Shield Silver 94 Trio HMO English (PDF, 2MB)
Spanish (PDF, 2MB)
 

We offer American Indian and Alaska Native plans for each metal level that are available only to eligible American Indians and Alaska Natives through Covered California. These plans differ from the standard metal level plans in that they allow American Indian and Alaska Native members to access covered services from American Indian and Alaskan Native providers for no out-of-pocket costs. In addition to the Alaska Native and American Indian versions of the standard metal level plans, we offer a $0 cost share PPO plan to American Indian and Alaska Native members who qualify based on household income. Members can choose to access covered services through a Blue Shield participating provider or non-network provider for an out-of-pocket cost.

Alaska Native and American Indian PPO Plans Summary of Benefits
Blue Shield Platinum 90 PPO AI-AN English (PDF, 2MB)
Spanish (PDF, 2MB)

 

Blue Shield Platinum 90 Trio HMO AI-AN English (PDF, 2MB)
Spanish (PDF, 2MB)
 
 
Blue Shield Gold 80 PPO AI-AN English (PDF, 2MB)
Spanish  (PDF, 2MB)

 

Blue Shield Gold 80 Trio HMO AI-AN

English (PDF, 2MB)
Spanish (PDF, 2MB)

 
Blue Shield Silver 70 PPO AI-AN English (PDF, 2MB)
Spanish (PDF, 2MB)
 

 

Blue Shield Silver 70 Trio HMO AI-AN English (PDF, 2MB)
Spanish (PDF, 2MB)
 
 
Blue Shield Bronze 60 PPO AI-AN English (PDF, 2MB)
Spanish (PDF, 2MB)
 
 
Blue Shield Bronze 60 HDHP PPO AI-AN English (PDF, 2MB)
Spanish (PDF, 2MB)
 
 
Blue Shield $0 Cost Share PPO AI-AN English (PDF, 2MB)
Spanish (PDF, 2MB)
 
 
Blue Shield $0 Cost Share Trio HMO AI-AN  English (PDF, 2MB)
Spanish (PDF, 2MB)
 

 

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    PO Box 272540

    Chico, CA 95927-2540

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Health insurance products are offered by Blue Shield of California Life & Health Insurance Company. Health plans are offered by Blue Shield of California.