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 2020 Benefit Summaries | Forms and Applications | Benefit Modification Brochures | Group administrator guide | Employer Connection provides resources for your clients | Network
| Full PPO Savings Two-Tier Plans | Summary of Benefits | Optional Benefits | Disclosures |
| Full PPO Savings Two-Tier Embedded Deductible 1400/2800/2800 |
English (PDF, 1MB) Spanish (PDF, 196KB) |
Hearing aid (PDF, 989KB) |
English (PDF, 25KB) |
| Full PPO Savings Two-Tier Embedded Deductible 1500/2800/3000 |
English (PDF, 1MB) Spanish (PDF, 196KB) |
Hearing aid (PDF, 989KB) |
English (PDF, 25KB) |
| Full PPO Savings Two-Tier Embedded Deductible 1500/2800/3000 100% |
English (PDF, 1MB) Spanish (PDF, 196KB) |
Hearing aid (PDF, 989KB) |
English (PDF, 25KB) |
| Full PPO Savings Two-Tier Embedded Deductible 1500/2800/3000 with $0 HDHP Preventive Drug Benefit |
English (PDF, 1MB) Spanish (PDF, 196KB) |
Hearing aid (PDF, 989KB) |
English (PDF, 25KB) |
| Full PPO Savings Two-Tier Embedded Deductible 1800/2800/3600 |
English (PDF, 1MB) Spanish (PDF, 196KB) |
Hearing aid (PDF, 989KB) |
English (PDF, 25KB) |
| Full PPO Savings Two-Tier Embedded Deductible 2250/2800/4500 |
English (PDF, 1MB) Spanish (PDF, 196KB) |
Hearing aid (PDF, 989KB) |
English (PDF, 25KB) |
| Full PPO Savings Two-Tier Embedded Deductible 2250/2800/4500 with $0 HDHP Preventive Drug Benefit |
English (PDF, 1MB) Spanish (PDF, 196KB) |
Hearing aid (PDF, 989KB) |
English (PDF, 25KB) |
| Full PPO Savings Plans | Summary of Benefits | Optional Benefits | Disclosures |
| Full PPO Savings Embedded Deductible 2800 | English (PDF, 1MB) Spanish (PDF, 196KB) |
Hearing aid (PDF, 989KB) |
English (PDF, 25KB) |
| Full PPO Savings Embedded Deductible 3000 | English (PDF, 1MB) Spanish (PDF, 196KB) |
Hearing aid (PDF, 989KB) |
English (PDF, 25KB) |
| Full PPO Savings Embedded Deductible 3000 100% | English (PDF, 1MB) Spanish (PDF, 196KB) |
Hearing aid (PDF, 989KB) |
English (PDF, 25KB) |
| Full PPO Savings Embedded Deductible 3500 | English (PDF, 1MB) Spanish (PDF, 196KB) |
Hearing aid (PDF, 989KB) |
English (PDF, 25KB) |
| Full PPO Savings Embedded Deductible 4000 |
Hearing aid (PDF, 989KB) |
English (PDF, 25KB) | |
| Full PPO Savings Embedded Deductible 4400 100% |
Hearing aid (PDF, 989KB) |
English (PDF, 25KB) | |
| Full PPO Savings Embedded Deductible 5500 | English (PDF, 1MB) Spanish (PDF, 196KB) |
Hearing aid (PDF, 989KB) |
English (PDF, 25KB) |
| Tandem PPO Plans | Summary of Benefits | Optional Benefits | Disclosures |
| Tandem PPO No Network Deductible 10 100/50 | English (PDF, 1MB) Spanish (PDF, 196KB) |
Hearing aid (PDF, 989KB) |
English (PDF, 25KB) |
| Tandem PPO Combined Deductible 0-250 80/60 |
English (PDF, 1MB) Spanish (PDF, 196KB) |
Hearing aid (PDF, 989KB) |
English (PDF, 25KB) |
| Tandem PPO Combined Deductible 0-250 90/70 |
English (PDF, 1MB) Spanish (PDF, 196KB) |
Hearing aid (PDF, 989KB) |
English (PDF, 25KB) |
| Tandem PPO Combined Deductible 0-400 90/70 |
English (PDF, 1MB) Spanish (PDF, 196KB) |
Hearing aid (PDF, 989KB) |
English (PDF, 25KB) |
| Tandem PPO Combined Deductible 10-250 90/70 |
English (PDF, 1MB) Spanish (PDF, 196KB) |
Hearing aid (PDF, 989KB) |
English (PDF, 25KB) |
| Tandem PPO Combined Deductible 15-250 90/70 |
English (PDF, 1MB) Spanish (PDF, 196KB) |
Hearing aid (PDF, 989KB) |
English (PDF, 25KB) |
| Tandem PPO Combined Deductible 20-200 90/70 |
English (PDF, 1MB) Spanish (PDF, 196KB) |
Hearing aid (PDF, 989KB) |
English (PDF, 25KB) |
| Tandem PPO Combined Deductible 20-250 80/60 |
English (PDF, 1MB) Spanish (PDF, 196KB) |
Hearing aid (PDF, 989KB) |
English (PDF, 25KB) |
| Tandem PPO Combined Deductible 25-250 80/60 |
English (PDF, 1MB) Spanish (PDF, 196KB) |
Hearing aid (PDF, 989KB) |
English (PDF, 25KB) |
| Tandem PPO Combined Deductible 25-250 90/60 | English (PDF, 1MB) Spanish (PDF, 196KB) |
Hearing aid (PDF, 989KB) |
English (PDF, 25KB) |
| Tandem PPO Combined Deductible Value 10-1000 90/70 |
English (PDF, 1MB) Spanish (PDF, 196KB) |
Hearing aid (PDF, 989KB) |
English (PDF, 25KB) |
| Tandem PPO Split Deductible 0-1750 80/60 |
English (PDF, 1MB) Spanish (PDF, 196KB) |
Hearing aid (PDF, 989KB) |
English (PDF, 25KB) |
| Tandem PPO Split Deductible 0-500 80/60 | English (PDF, 1MB) Spanish (PDF, 196KB) |
Hearing aid (PDF, 989KB) |
English (PDF, 25KB) |
| Tandem PPO Split Deductible 10-250 90/70 | English (PDF, 1MB) Spanish (PDF, 196KB) |
Hearing aid (PDF, 989KB) |
English (PDF, 25KB) |
| Tandem PPO Split Deductible 20-500 80/60 | English (PDF, 1MB) Spanish (PDF, 196KB) |
Hearing aid (PDF, 989KB) |
English (PDF, 25KB) |
| Tandem PPO Split Deductible 25-750 80/60 | English (PDF, 1MB) Spanish (PDF, 196KB) |
Hearing aid (PDF, 989KB) |
English (PDF, 25KB) |
| Tandem PPO Split Deductible 30-1500 80/50 | English (PDF, 1MB) Spanish (PDF, 196KB) |
Hearing aid (PDF, 989KB) |
English (PDF, 25KB) |
| Tandem PPO Split Deductible 35-1000 80/60 | English (PDF, 1MB) Spanish (PDF, 196KB) |
Hearing aid (PDF, 989KB) |
English (PDF, 25KB) |
| Tandem PPO Split Deductible 40-3000 70/50 | English (PDF, 1MB) Spanish (PDF, 196KB) |
Hearing aid (PDF, 989KB) |
English (PDF, 25KB) |
| Tandem PPO Savings Plans | Summary of Benefits | Optional Benefits | Disclosures |
| Tandem PPO Savings Embedded Deductible 3000 | English (PDF, 1MB) |