The SOB documents will include the coverage information you are used to seeing but in a much-simplified format. The format makes it easier for members to read and understand their plan benefits. SOBs will be included in new business proposals and renewals, open-enrollment materials, as well as member welcome kits as part of the Evidence of Coverage (EOC).
See FAQs about the new Summary of Benefits.
When providing the Summary of Benefits to an applicant or Blue Shield member, you must also include a Notice of Language Assistance (PDF, 1.04MB).
In addition, the Summary of Benefits and Coverage (SBC) Forms, provide your clients with an easy-to-understand overview of what our plans for groups of 101 and above cover. You can download SBC Forms and other resources for these plans:
January 2023 Benefit Summaries | Forms and Applications | Benefit Modification Brochures | Group administrator guide | Employer Connection provides resources for your clients | Network
Full PPO Plans | Summary of Benefits | Optional Benefits | Disclosures |
Full PPO No Network Deductible 10 100/50 | English (PDF, 1 MB) Spanish (PDF, 196 KB) |
Hearing aid (PDF, 987 KB) |
English (PDF, 1.1 MB) |
Full PPO No Network Deductible 20 100/50 | English (PDF, 1 MB) Spanish (PDF, 196 KB) |
Hearing aid (PDF, 987 KB) |
English (PDF, 1.1 MB) |
Full PPO Combined Deductible 0-250 80/60 |
Hearing aid (PDF, 987 KB) |
English (PDF, 1.1 MB) | |
Full PPO Combined Deductible 0-250 90/70 |
Hearing aid (PDF, 987 KB) |
English (PDF, 1.1 MB) | |
Full PPO Combined Deductible 0-400 90/70 |
Hearing aid (PDF, 987 KB) |
English (PDF, 1.1 MB) | |
Full PPO Combined Deductible 10-250 90/70 |
Hearing aid (PDF, 987 KB) |
English (PDF, 1.1 MB) | |
Full PPO Combined Deductible 10-500 90/70 |
Hearing aid (PDF, 987 KB) |
English (PDF, 1.1 MB) | |
Full PPO Combined Deductible 15-250 90/70 | English (PDF, 1 MB) Spanish (PDF, 196 KB) |
Hearing aid (PDF, 987 KB) |
English (PDF, 1.1 MB) |
Full PPO Combined Deductible 20-200 90/70 | English (PDF, 1 MB) Spanish (PDF, 196 KB) |
Hearing aid (PDF, 987 KB) |
English (PDF, 1.1 MB) |
Full PPO Combined Deductible 20-250 80/60 | English (PDF, 1 MB) Spanish (PDF, 196 KB) |
Hearing aid (PDF, 987 KB) |
English (PDF, 1.1 MB) |
Full PPO Combined Deductible 25-250 80/60 | English (PDF, 1 MB) Spanish (PDF, 196 KB) |
Hearing aid (PDF, 987 KB) |
English (PDF, 1.1 MB) |
Full PPO Combined Deductible 25-250 90/60 | English (PDF, 1 MB) Spanish (PDF, 196 KB) |
Hearing aid (PDF, 987 KB) |
English (PDF, 1.1 MB) |
Full PPO Combined Deductible 30-500 90/60 | English (PDF, 1 MB) Spanish (PDF, 196 KB) |
Hearing aid (PDF, 987 KB) |
English (PDF, 1.1 MB) |
Full PPO Combined Deductible 30-750 80/60 | English (PDF, 1 MB) Spanish (PDF, 196 KB) |
Hearing aid (PDF, 987 KB) |
English (PDF, 1.1 MB) |
Full PPO Combined Deductible 35-500 80/60 | English (PDF, 1 MB) Spanish (PDF, 196 KB) |
Hearing aid (PDF, 987 KB) |
English (PDF, 1.1 MB) |
Full PPO Combined Deductible 40-6350 80/50 | English (PDF, 1 MB) Spanish (PDF, 196 KB) |
Hearing aid (PDF, 987 KB) |
English (PDF, 1.1 MB) |
Full PPO Combined Deductible Value 10-1000 90/70 | English (PDF, 1 MB) Spanish (PDF, 196 KB) |
Hearing aid (PDF, 987 KB) |
English (PDF, 1.1 MB) |
Full PPO Combined Deductible Value 15-1500 80/50 | English (PDF, 1 MB) Spanish (PDF, 196 KB) |
Hearing aid (PDF, 987 KB) |
English (PDF, 1.1 MB) |
Full PPO Combined Deductible Value 20-2000 80/50 | English (PDF, 1 MB) Spanish (PDF, 196 KB) |
Hearing aid (PDF, 987 KB) |
English (PDF, 1.1 MB) |
Full PPO Combined Deductible Value 25-2500 80/50 | English (PDF, 1 MB) Spanish (PDF, 196 KB) |
Hearing aid (PDF, 987 KB) |
English (PDF, 1.1 MB) |
Full PPO Combined Deductible Value 30-3000 80/50 | English (PDF, 1 MB) Spanish (PDF, 196 KB) |
Hearing aid (PDF, 987 KB) |
English (PDF, 1.1 MB) |
Full PPO Combined Deductible Value 40-4000 80/50 | English (PDF, 1 MB) Spanish (PDF, 196 KB) |
Hearing aid (PDF, 987 KB) |
English (PDF, 1.1 MB) |
Full PPO Split Deductible 0-1750 80/60 | English (PDF, 1 MB) Spanish (PDF, 196 KB) |
Hearing aid (PDF, 987 KB) |
English (PDF, 1.1 MB) |
Full PPO Split Deductible 0-500 80/60 | English (PDF, 1 MB) Spanish (PDF, 196 KB) |
Hearing aid (PDF, 987 KB) |
English (PDF, 1.1 MB) |
Full PPO Split Deductible 10-250 90/70 | English (PDF, 1 MB) Spanish (PDF, 196 KB) |
Hearing aid (PDF, 987 KB) |
English (PDF, 1.1 MB) |
Full PPO Split Deductible 15-500 90/60 | English (PDF, 1 MB) Spanish (PDF, 196 KB) |
Hearing aid (PDF, 987 KB) |
English (PDF, 1.1 MB) |
Full PPO Split Deductible 20-500 80/60 | English ((PDF, 47 KB) Spanish (PDF, 196 KB) |
Hearing aid (PDF, 987 KB) |
English (PDF, 1.1 MB) |
Full PPO Split Deductible 25-750 80/60 | English (PDF, 1 MB) Spanish (PDF, 196 KB) |
Hearing aid (PDF, 987 KB) |
English (PDF, 1.1 MB) |
Full PPO Split Deductible 30-2000 70/50 | English (PDF, 1 MB) Spanish (PDF, 196 KB) |
Hearing aid (PDF, 987 KB) |
English (PDF, 1.1 MB) |
Full PPO Split Deductible 35-1000 80/60 | English (PDF, 1 MB) Spanish (PDF, 196 KB) |
Hearing aid (PDF, 987 KB) |
English (PDF, 1.1 MB) |
Full PPO Split Deductible 40-4000 70/50 | English (PDF, 1 MB) Spanish (PDF, 196 KB) |
Hearing aid (PDF, 987 KB) |
English (PDF, 1.1 MB) |
Full PPO Split Deductible 50-5000 70/50 | English (PDF, 1 MB) Spanish (PDF, 196 KB) |
Hearing aid (PDF, 987 KB) |
English (PDF, 1.1 MB) |
Full PPO Split Deductible 50-6350 70/50 | English (PDF, 1 MB) Spanish (PDF, 196 KB) |
Hearing aid (PDF, 987 KB) |
English (PDF, 1.1 MB) |
Full PPO Savings Two-Tier Plans | Summary of Benefits | Optional Benefits | Disclosures |
Full PPO Savings Two-Tier Embedded Deductible 1600/3200/3200 90/70 |
English (PDF, 1 MB) Spanish (PDF, 196 KB) |
Hearing aid (PDF, 987 KB) |
English (PDF, 1.1 MB) |
Full PPO Savings Two-Tier Embedded Deductible 1600/3200/3200 90/60 |
English (PDF, 1 MB) Spanish (PDF, 196 KB) |
Hearing aid (PDF, 987 KB) |
English (PDF, 1.1 MB) |
Full PPO Savings Two-Tier Embedded Deductible 1600/3200/3200 100% |
English (PDF, 1 MB) Spanish (PDF, 196 KB) |
Hearing aid (PDF, 987 KB) |
English (PDF, 1.1 MB) |
Full PPO Savings Two-Tier Embedded Deductible 1600/3200/3200 with $0 HDHP Preventive Drug Benefit |
English (PDF, 1 MB) Spanish (PDF, 196 KB) |
Hearing aid (PDF, 987 KB) |
English (PDF, 1.1 MB) |
Full PPO Savings Two-Tier Embedded Deductible 1800/3200/3600 |
English (PDF, 1 MB) Spanish (PDF, 196 KB) |
Hearing aid (PDF, 987 KB) |
English (PDF, 1.1 MB) |
Full PPO Savings Two-Tier Embedded Deductible 2250/3200/4500 |
English (PDF, 1 MB) Spanish (PDF, 196 KB) |
Hearing aid (PDF, 987 KB) |
English (PDF, 1.1 MB) |
Full PPO Savings Two-Tier Embedded Deductible 2250/3200/4500 with $0 HDHP Preventive Drug Benefit |
English (PDF, 1 MB) Spanish (PDF, 196 KB) |
Hearing aid (PDF, 987 KB) |
English (PDF, 1.1 MB) |
Full PPO Savings Two-Tier Embedded Deductible 1600/3200/3200 with Value Formulary |
English (PDF, 1 MB) Spanish (PDF, 196 KB) |
Hearing aid (PDF, 987 KB) |
English (PDF, 1.1 MB) |
Tandem PPO Savings Two-Tier Embedded Deductible 1600/3200/3200 |
English (PDF, 1 MB) Spanish (PDF, 196 KB) |
Hearing aid (PDF, 987 KB) |
English (PDF, 1.1 MB) |
Full PPO Savings Plans | Summary of Benefits | Optional Benefits | Disclosures |
Full PPO Savings Embedded Deductible 3200/5200 | English (PDF, 1 MB) Spanish (PDF, 196 KB) |
Hearing aid (PDF, 987 KB) |
English (PDF, 1.1 MB) |
Full PPO Savings Embedded Deductible 3200/6000 | English (PDF, 1 MB) Spanish (PDF, 196 KB) |
Hearing aid (PDF, 987 KB) |
English (PDF, 1.1MB) |
Full PPO Savings Embedded Deductible 3200 100% | English (PDF, 1 MB) Spanish (PDF, 196 KB) |
Hearing aid (PDF, 987 KB) |
English (PDF, 1.1 MB) |
Full PPO Savings Embedded Deductible 3500 | English (PDF, 1 MB) Spanish (PDF, 196 KB) |
Hearing aid (PDF, 987 KB) |
English (PDF, 1.1 MB) |
Full PPO Savings Embedded Deductible 4000 |
Hearing aid (PDF, 987 KB) |
English (PDF, 1.1 MB) | |
Full PPO Savings Embedded Deductible 4400 100% |
Hearing aid (PDF, 987 KB) |
English (PDF, 1.1 MB) | |
Full PPO Savings Embedded Deductible 5500 | English (PDF, 1 MB) Spanish (PDF, 196 KB) |
Hearing aid (PDF, 987 KB) |
English (PDF, 1.1 MB) |
Full PPO Savings Embedded Deductible 5500 with Value Formulary | English (PDF, 1 MB) Spanish (PDF, 196 KB) |
Hearing aid (PDF, 987 KB) |
English (PDF, 1.1 MB) |
Full PPO Savings Embedded Deductible 6350 100% | English (PDF, 1 MB) Spanish (PDF, 196 KB) |
Hearing aid (PDF, 987 KB) |
English (PDF, 1.1 MB) |
Tandem PPO Plans | Summary of Benefits | Optional Benefits | Disclosures |
Tandem PPO No Network Deductible 10 100/50 | English (PDF, 1 MB) Spanish (PDF, 196 KB) |
Hearing aid (PDF, 987 KB) |
English (PDF, 1.1 MB) |
Tandem PPO Combined Deductible 0-250 80/60 |
English (PDF, 1 MB) Spanish (PDF, 196 KB) |
Hearing aid (PDF, 987 KB) |
English (PDF, 1.1 MB) |
Tandem PPO Combined Deductible 0-250 90/70 |
English (PDF, 1 MB) Spanish (PDF, 196 KB) |
Hearing aid (PDF, 987 KB) |
English (PDF, 1.1 MB) |
Tandem PPO Combined Deductible 0-400 90/70 |
English (PDF, 1 MB) Spanish (PDF, 196 KB) |
Hearing aid (PDF, 987 KB) |
English (PDF, 1.1 MB) |
Tandem PPO Combined Deductible 10-250 90/70 |
English (PDF, 1 MB) Spanish (PDF, 196 KB) |
Hearing aid (PDF, 987 KB) |
English (PDF, 1.1 MB) |
Tandem PPO Combined Deductible 15-250 90/70 |
English (PDF, 1 MB) Spanish (PDF, 196 KB) |
Hearing aid (PDF, 987 KB) |
English (PDF, 1.1 MB) |
Tandem PPO Combined Deductible 20-250 80/60 |
English (PDF, 1 MB) Spanish (PDF, 196 KB) |
Hearing aid (PDF, 987 KB) |
English (PDF, 1.1 MB) |
Tandem PPO Split Deductible 0-1750 80/60 |
English (PDF, 1 MB) Spanish (PDF, 196 KB) |
Hearing aid (PDF, 987 KB) |
English (PDF, 1.1 MB) |
Tandem PPO Split Deductible 0-500 80/60 | English (PDF, 1 MB) Spanish (PDF, 196 KB) |
Hearing aid (PDF, 987 KB) |
English (PDF, 1.1 MB) |
Tandem PPO Split Deductible 10-250 90/70 | English (PDF, 1 MB) Spanish (PDF, 196 KB) |
Hearing aid (PDF, 987 KB) |
English (PDF, 1.1 MB) |
Tandem PPO Split Deductible 20-500 80/60 | English (PDF, 1 MB) Spanish (PDF, 196 KB) |
Hearing aid (PDF, 987 KB) |