January 2020 Summary of Benefits

Large Groups (101 and above)

For 2020 medical plans, the current plan Benefit Summary documents (except for Active Choice) will be replaced by new Summary of Benefits (SOB) documents. The SOB documents will include the coverage information you are used to seeing but in a much simplified format. The new 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).

Click here for 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:

PPO plans
HMO plans
HSA-compatible plans
Trio HMO plans
Point of service plans
Prescription drug options

Show full contents

Prescription drug options

Access+ HMO Plans	Summary of Benefits	Optional Benefits	Disclosures
Access+ HMO® Zero Admit 10	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Access+ HMO Zero Admit 15	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Access+ HMO® Zero Admit 20	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Access+ HMO® Zero Admit 30	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Access+ HMO® Per Admit 10-250	English(PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Access+ HMO® Per Admit 20-250	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Access+ HMO® Per Admit 20-500	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Access+ HMO® Per Admit 25-750	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Access+ HMO® Per Admit 40-1000	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Access+ HMO® Per Day 15-500	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Access+ HMO® Per Day 25-750	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Access+ HMO® Facility Coinsurance 15-20%	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Access+ HMO® Facility Coinsurance 20-20%	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Access+ HMO® Facility Coinsurance 25-25%	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Access+ HMO Facility Coinsurance 30-30%	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Access+ HMO® Facility Coinsurance 40-40%	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Access+ HMO® Zero Facility Deductible 30-20%	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Access+ HMO Facility Deductible 15-10%/250	English (PDF, 47KB) Spanish (PDF, 47KB))	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Access+ HMO Facility Deductible 15-10%/500	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Access+ HMO Facility Deductible 15-10%/750	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Access+ HMO® Facility Deductible 15-10%/1500	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Access+ HMO® Facility Deductible 20-25%/1500	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Access+ HMO® Facility Deductible 30-10%/1500	English(PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Access+ HMO® Facility Deductible 30-30%/2000	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Access+ HMO® Facility Deductible 40-40%/2000	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Access+ HMO® Facility Deductible 40-40%/5800	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage

Access+ HMO SaveNet Plans	Summary of Benefits	Optional Benefits	Disclosures
Access+ HMO® SaveNet Zero Admit 10	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Access+ HMO® SaveNet Zero Admit 20	English (PDF, 47KB) Spanish(PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Access+ HMO® SaveNet Zero Admit 30	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Access+ HMO® SaveNet Per Admit 10-250	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Access+ HMO® SaveNet Per Admit 20-500	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Access+ HMO® SaveNet Per Admit 25-750	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Access+ HMO® SaveNet Per Admit 40-1000	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Access+ HMO® SaveNet Facility Coinsurance 15-20%	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Access+ HMO® SaveNet Facility Coinsurance 20-20%	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Access+ HMO® SaveNet Facility Coinsurance 25-25%	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Access+ HMO® SaveNet Facility Coinsurance 40-40%	English (PDF, 47KB) Spanish (PDF,47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Access+ HMO® SaveNet Facility Deductible 15-10%/1500	English (PDF, 47KB) Spanish (PDF,47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Access+ HMO® SaveNet Facility Deductible 20-25%/1500	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Access+ HMO® SaveNet Facility Deductible 30-30%/2000	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Access+ HMO® SaveNet Facility Deductible 40-40%/2000	English (PDF, 47KB) Spanish (PDF,47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Access+ HMO® SaveNet Facility Deductible 40-40%/5800	English (PDF, 47KB) Spanish (PDF,47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage

Local Access+ HMO Plans	Summary of Benefits	Optional Benefits	Disclosures
Local Access+ HMO® Zero Admit 10	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Local Access+ HMO® Zero Admit 20	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Local Access+ HMO® Zero Admit 30	English (PDF, 47KB)) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Local Access+ HMO® Per Admit 10-250	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Local Access+ HMO® Per Admit 20-500	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Local Access+ HMO® Per Admit 25-750	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Local Access+ HMO® Per Admit 40-1000	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx PrescriptionDrug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Local Access+ HMO® Facility Coinsurance 15-20%	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Local Access+ HMO® Facility Coinsurance 20-20%	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Local Access+ HMO® Facility Coinsurance \|25-25%	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Local Access+ HMO® Facility Coinsurance 40-40%	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Local Access+ HMO® Facility Deductible 15-10%/1500	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Local Access+ HMO® Facility Deductible 20-25%/1500	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Local Access+ HMO® Facility Deductible 30-30%/2000	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Local Access+ HMO® Facility Deductible 40-40%/2000	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Local Access+ HMO® Facility Deductible 40-40%/5800	English (PDF, 47KB) Spanish (PDF,47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage

Trio HMO Plans	Summary of Benefits	Optional Benefits	Disclosures
Trio HMO Zero Admit 10	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Trio HMO Zero Admit 15	English (PDF, 47KB) Spanish (PDF,47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Trio HMO Zero Admit 20	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Trio HMO Zero Admit 30	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Trio HMO Per Admit 10-250	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Trio HMO Per Admit 20-250	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Trio HMO Per Admit 20-500	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Trio HMO Per Admit 25-750	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Trio HMO Per Admit 40-1000	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Trio HMO Per Day 15-500	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Trio HMO Per Day 25-750	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Trio HMO Facility Coinsurance 15-20%	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Trio HMO Facility Coinsurance 20-20%	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Trio HMO Facility Coinsurance 25-25%	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Trio HMO Facility Coinsurance 30-30%	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Trio HMO Facility Coinsurance 40-40%	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Trio HMO Facility Deductible 15-10%/250	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Trio HMO Facility Deductible 15-10%/500	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Trio HMO Facility Deductible 15-10%/750	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Trio HMO Facility Deductible 15-10%/1500	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Trio HMO Facility Deductible 20-25%/1500	English (PDF, 47KB) Spanish (PDF,47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Trio HMO Facility Deductible 30-10%/1500	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Trio HMO Facility Deductible 30-30%/2000	English (PDF, 47KB) Spanish (PDF,47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Trio HMO Facility Deductible 40-40%/2000	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx PrescriptionDrug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Trio HMO Facility Deductible 40-40%/5800	English (PDF, 47KB) Spanish (PDF, 47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage
Trio HMO Zero Facility Deductible 30-20%	English (PDF, 47KB) Spanish (PDF,47KB)	Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Chiropractic (PDF, 104KB) Chiropractic and acupuncture (PDF, 104KB) Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage Spanish With Basic Rx Prescription Drug Coverage With Enhanced or Premier Rx Prescription Drug Coverage

Show full contents

Added Advantage POS^SM plans

Summary of Benefits

Optional Benefits

Disclosures

Added Advantage POS^SM
300-100/90/70

English (PDF,48KB)
Spanish (PDF, 47KB)

Chiropractic (PDF, 48KB)
Chiropractic and Acupuncture (PDF, 104KB)
Hearing aid (PDF, 104KB)
Infertility 50% (PDF, 104KB)
Infertility 80% (PDF, 104KB)
Infertility 95% (PDF, 104KB)

Spanish
Chiropractic (PDF, 104KB)
Chiropractic and acupuncture (PDF, 104KB)
Hearing aid (PDF, 104KB)
Infertility 50% (PDF, 104KB)
Infertility 80% (PDF, 104KB)
Infertility 95% (PDF, 104KB)

With Basic Rx Prescription Drug Coverage
With Enhanced or Premier Rx Prescription Drug Coverage

Spanish
With Basic Rx Prescription Drug Coverage
With Enhanced or Premier Rx Prescription Drug Coverage

Added Advantage POS^SM
500-100/80/60

English (PDF, 48KB)Spanish (PDF, 47KB)

Chiropractic (PDF, 48KB)
Chiropractic and Acupuncture (PDF, 104KB)
Hearing aid (PDF, 104KB)
Infertility 50% (PDF, 104KB)
Infertility 80% (PDF, 104KB)
Infertility 95% (PDF, 104KB)

Spanish
Chiropractic (PDF, 104KB)
Chiropractic and acupuncture (PDF, 104KB)
Hearing aid (PDF, 104KB)
Infertility 50% (PDF, 104KB)
Infertility 80% (PDF, 104KB)
Infertility 95% (PDF, 104KB)

With Basic Rx Prescription Drug Coverage
With Enhanced or Premier Rx Prescription Drug Coverage

Spanish
With Basic Rx Prescription Drug Coverage
With Enhanced or Premier Rx Prescription Drug Coverage

Show full contents

Prescription drug options

Full PPO Plans	Summary of Benefits	Optional Benefits	Disclosures
Full PPO No Network Deductible 10 100/50	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB)Infertility 95% (PDF, 104KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	English (PDF, 25KB) Spanish (PDF, 25KB)
Full PPO No Network Deductible 20 100/50	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB)Infertility 95% (PDF, 104KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	English (PDF, 25KB) Spanish (PDF, 25KB)
Full PPO Combined Deductible 0-400 90/70	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB)Infertility 95% (PDF, 104KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	English (PDF, 25KB) Spanish (PDF, 25KB)
Full PPO Combined Deductible 10-250 90/70	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB)Infertility 95% (PDF, 104KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	English (PDF, 25KB) Spanish (PDF, 25KB)
Full PPO Combined Deductible 10-500 90/70	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB)Infertility 95% (PDF, 104KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	English (PDF, 25KB) Spanish (PDF, 25KB)
Full PPO Combined Deductible 15-250 90/70	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB)Infertility 95% (PDF, 104KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	English (PDF, 25KB) Spanish (PDF, 25KB)
Full PPO Combined Deductible 20-200 90/70	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB)Infertility 95% (PDF, 104KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	English (PDF, 25KB) Spanish (PDF, 25KB)
Full PPO Combined Deductible 20-250 80/60	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB)Infertility 95% (PDF, 104KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	English (PDF, 25KB) Spanish (PDF, 25KB)
Full PPO Combined Deductible 25-250 80/60	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB)Infertility 95% (PDF, 104KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	English (PDF, 25KB) Spanish (PDF, 25KB)
Full PPO Combined Deductible 25-250 90/60	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB)Infertility 95% (PDF, 104KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	English (PDF, 25KB) Spanish (PDF, 25KB)
Full PPO Combined Deductible 30-500 90/60	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB)Infertility 95% (PDF, 104KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	English (PDF, 25KB) Spanish (PDF, 25KB)
Full PPO Combined Deductible 30-750 80/60	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB)Infertility 95% (PDF, 104KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	English (PDF, 25KB) Spanish (PDF, 25KB)
Full PPO Combined Deductible 35-500 80/60	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB)Infertility 95% (PDF, 104KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	English (PDF, 25KB) Spanish (PDF, 25KB)
Full PPO Combined Deductible Value 10-1000 90/70	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB)Infertility 95% (PDF, 104KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	English (PDF, 25KB) Spanish (PDF, 25KB)
Full PPO Combined Deductible Value 15-1500 80/50	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB)Infertility 95% (PDF, 104KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	English (PDF, 25KB) Spanish (PDF, 25KB)
Full PPO Combined Deductible Value 20-2000 80/50	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB)Infertility 95% (PDF, 104KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	English (PDF, 25KB) Spanish (PDF, 25KB)
Full PPO Combined Deductible Value 25-2500 80/50	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB)Infertility 95% (PDF, 104KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	English (PDF, 25KB) Spanish (PDF, 25KB)
Full PPO Combined Deductible Value 30-3000 80/50	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB)Infertility 95% (PDF, 104KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	English (PDF, 25KB) Spanish (PDF, 25KB)
Full PPO Combined Deductible Value 40-4000 80/50	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB)Infertility 95% (PDF, 104KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	English (PDF, 25KB) Spanish (PDF, 25KB)
Full PPO Combined Deductible Value 50-4500 80/50	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB)Infertility 95% (PDF, 104KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	English (PDF, 25KB) Spanish (PDF, 25KB
Full PPO Split Deductible 0-1750 80/60	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB)Infertility 95% (PDF, 104KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	English (PDF, 25KB) Spanish (PDF, 25KB
Full PPO Split Deductible 10-250 90/70	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB)Infertility 95% (PDF, 104KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	English (PDF, 25KB) Spanish (PDF, 25KB
Full PPO Split Deductible 15-500 90/60	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB)Infertility 95% (PDF, 104KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	English (PDF, 25KB) Spanish (PDF, 25KB)
Full PPO Split Deductible 20-500 80/60	English ((PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB)Infertility 95% (PDF, 104KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	English (PDF, 25KB) Spanish (PDF, 25KB)
Full PPO Split Deductible 25-750 80/60	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB)Infertility 95% (PDF, 104KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	English (PDF, 25KB) Spanish (PDF, 25KB)
Full PPO Split Deductible 35-1000 80/60	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB)Infertility 95% (PDF, 104KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	English (PDF, 25KB) Spanish (PDF, 25KB)
Full PPO Split Deductible 30-2000 70/50	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB)Infertility 95% (PDF, 104KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	English (PDF, 25KB) Spanish (PDF, 25KB)
Full PPO Split Deductible 40-4000 70/50	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB)Infertility 95% (PDF, 104KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	English (PDF, 25KB) Spanish (PDF, 25KB)

Full PPO Savings Two-Tier Plans	Summary of Benefits	Optional Benefits	Disclosures
Full PPO Savings Two-Tier Embedded Deductible 1400/2800/2800	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 47KB) Infertility 80% (PDF, 47KB) Infertility 95% (PDF, 47KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 47KB) Infertility 80% (PDF, 47KB) Infertility 95% (PDF, 47KB)	English (PDF, 25KB) Spanish (PDF, 25KB)
Full PPO Savings Two-Tier Embedded Deductible 1500/2800/3000	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 47KB) Infertility 80% (PDF, 47KB) Infertility 95% (PDF, 47KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 47KB) Infertility 80% (PDF, 47KB) Infertility 95% (PDF, 47KB)	English (PDF, 25KB) Spanish (PDF, 25KB)
Full PPO Savings Two-Tier Embedded Deductible 1500/2800/3000 100%	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 47KB) Infertility 80% (PDF, 47KB) Infertility 95% (PDF, 47KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 47KB) Infertility 80% (PDF, 47KB) Infertility 95% (PDF, 47KB)	English (PDF, 25KB) Spanish (PDF, 25KB)
Full PPO Savings Two-Tier Embedded Deductible 1500/2800/3000 with Value-Based Tier Drug Benefit	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 47KB) Infertility 80% (PDF, 47KB) Infertility 95% (PDF, 47KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 47KB) Infertility 80% (PDF, 47KB) Infertility 95% (PDF, 47KB)	English (PDF, 25KB) Spanish (PDF, 25KB)
Full PPO Savings Two-Tier Embedded Deductible 1800/2800/3600	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 47KB) Infertility 80% (PDF, 47KB) Infertility 95% (PDF, 47KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 47KB) Infertility 80% (PDF, 47KB) Infertility 95% (PDF, 47KB)	English (PDF, 25KB) Spanish (PDF, 25KB)
Full PPO Savings Two-Tier Embedded Deductible 2250/2800/4500	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 47KB) Infertility 80% (PDF, 47KB) Infertility 95% (PDF, 47KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 47KB) Infertility 80% (PDF, 47KB) Infertility 95% (PDF, 47KB)	English (PDF, 25KB) Spanish (PDF, 25KB)
Full PPO Savings Two-Tier Embedded Deductible 2250/2800/4500 with Value-Based Tier Drug Benefit	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 47KB) Infertility 80% (PDF, 47KB) Infertility 95% (PDF, 47KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 47KB) Infertility 80% (PDF, 47KB) Infertility 95% (PDF, 47KB)	English (PDF, 25KB) Spanish (PDF, 25KB)

Full PPO Savings Plans	Summary of Benefits	Optional Benefits	Disclosures
Full PPO Savings Embedded Deductible 2800	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 47KB) Infertility 80% (PDF, 47KB) Infertility 95% (PDF, 47KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 47KB) Infertility 80% (PDF, 47KB) Infertility 95% (PDF, 47KB)	English (PDF, 25KB) Spanish (PDF, 25KB)
Full PPO Savings Embedded Deductible 3000	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 47KB) Infertility 80% (PDF, 47KB) Infertility 95% (PDF, 47KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 47KB) Infertility 80% (PDF, 47KB) Infertility 95% (PDF, 47KB)	English (PDF, 25KB) Spanish (PDF, 25KB)
Full PPO Savings Embedded Deductible 3000 100%	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 47KB) Infertility 80% (PDF, 47KB) Infertility 95% (PDF, 47KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 47KB) Infertility 80% (PDF, 47KB) Infertility 95% (PDF, 47KB)	English (PDF, 25KB) Spanish (PDF, 25KB)
Full PPO Savings Embedded Deductible 3500	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 47KB) Infertility 80% (PDF, 47KB) Infertility 95% (PDF, 47KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 47KB) Infertility 80% (PDF, 47KB) Infertility 95% (PDF, 47KB)	English (PDF, 25KB) Spanish (PDF, 25KB)
Full PPO Savings Embedded Deductible 4000	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 47KB) Infertility 80% (PDF, 47KB) Infertility 95% (PDF, 47KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 47KB) Infertility 80% (PDF, 47KB) Infertility 95% (PDF, 47KB)	English (PDF, 25KB) Spanish (PDF, 25KB)
Full PPO Savings Embedded Deductible 4400 100%	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 47KB) Infertility 80% (PDF, 47KB) Infertility 95% (PDF, 47KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 47KB) Infertility 80% (PDF, 47KB) Infertility 95% (PDF, 47KB)	English (PDF, 25KB) Spanish (PDF, 25KB)
Full PPO Savings Embedded Deductible 5500	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 47KB) Infertility 80% (PDF, 47KB) Infertility 95% (PDF, 47KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 47KB) Infertility 80% (PDF, 47KB) Infertility 95% (PDF, 47KB)	English (PDF, 25KB) Spanish (PDF, 25KB)
Tandem PPO Plans	Summary of Benefits	Optional Benefits	Disclosures
Tandem PPO Combined Deductible 0-400 90/70	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB)Infertility 95% (PDF, 104KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	English (PDF, 25KB) Spanish (PDF, 25KB)
Tandem PPO Combined Deductible 10-250 90/70	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB)Infertility 95% (PDF, 104KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	English (PDF, 25KB) Spanish (PDF, 25KB)
Tandem PPO Combined Deductible 15-250 90/70	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB)Infertility 95% (PDF, 104KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	English (PDF, 25KB) Spanish (PDF, 25KB)
Tandem PPO Combined Deductible 20-200 90/70	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB)Infertility 95% (PDF, 104KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	English (PDF, 25KB) Spanish (PDF, 25KB)
Tandem PPO Combined Deductible 20-250 80/60	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB)Infertility 95% (PDF, 104KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	English (PDF, 25KB) Spanish (PDF, 25KB)
Tandem PPO Combined Deductible 25-250 80/60	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB)Infertility 95% (PDF, 104KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	English (PDF, 25KB) Spanish (PDF, 25KB)
Tandem PPO Combined Deductible 25-250 90/60	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB)Infertility 95% (PDF, 104KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	English (PDF, 25KB) Spanish (PDF, 25KB)
Tandem PPO Combined Deductible Value 10-1000 90/70	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB)Infertility 95% (PDF, 104KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	English (PDF, 25KB) Spanish (PDF, 25KB)
Tandem PPO No Network Deductible 10 100/50	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB)Infertility 95% (PDF, 104KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	English (PDF, 25KB) Spanish (PDF, 25KB)
Tandem PPO Split Deductible 0-1750 80/60	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB)Infertility 95% (PDF, 104KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	English (PDF, 25KB) Spanish (PDF, 25KB)
Tandem PPO Split Deductible 10-250 90/70	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB)Infertility 95% (PDF, 104KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	English (PDF, 25KB) Spanish (PDF, 25KB))
Tandem PPO Split Deductible 20-500 80/60	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB)Infertility 95% (PDF, 104KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	English (PDF, 25KB) Spanish (PDF, 25KB)
Tandem PPO Split Deductible 25-750 80/60	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB)Infertility 95% (PDF, 104KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	English (PDF, 25KB) Spanish (PDF, 25KB)
Tandem PPO Split Deductible 30-1500 80/50	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB)Infertility 95% (PDF, 104KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	English (PDF, 25KB) Spanish (PDF, 25KB)
Tandem PPO Split Deductible 35-1000 80/60	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB)Infertility 95% (PDF, 104KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	English (PDF, 25KB) Spanish (PDF, 25KB)
Tandem PPO Split Deductible 40-3000 70/50	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB)Infertility 95% (PDF, 104KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	English (PDF, 25KB) Spanish (PDF, 25KB)
Tandem PPO Savings Embedded Deductible 3000	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB)Infertility 95% (PDF, 104KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	English (PDF, 25KB) Spanish (PDF, 25KB)
Tandem PPO Savings Embedded Deductible 4425	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB)Infertility 95% (PDF, 104KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	English (PDF, 25KB) Spanish (PDF, 25KB)

Active Choice PPO Plans	Summary of Benefits	Optional Benefits	Disclosures
Active Choice® 500 80/50	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	English (PDF, 25KB) Spanish (PDF, 25KB)
Active Choice® 750 80/60	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	English (PDF, 25KB) Spanish (PDF, 25KB)
Active Choice® 750 70/50	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	English (PDF, 25KB) Spanish (PDF, 25KB)
Active Choice® 750 70/50 1000 Deductible	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	English (PDF, 25KB) Spanish (PDF, 25KB)
Active Choice® 500 80/50 1500 Deductible	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	English (PDF, 25KB) Spanish (PDF, 25KB)

Not marketed PPO plans*	Summary of Benefits	Optional Benefits	Disclosures
Shield Spectrum PPO 250-90/70 Standard	English (PDF, 47KB) Spanish (PDF, 47KB)	Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB)Infertility 95% (PDF, 104KB) Spanish Hearing aid (PDF, 104KB) Infertility 50% (PDF, 104KB) Infertility 80% (PDF, 104KB) Infertility 95% (PDF, 104KB)	English (PDF, 25KB) Spanish (PDF, 25KB)

EPO Plans (Non-Marketed Plans)	Summary of Benefits	Optional Benefits	Disclosures
Full EPO Per Admit 10-250	English (PDF, 47KB) Spanish (PDF, 47KB)

January 2020 Summary of Benefits

Large Groups (101 and above)

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