January 2022 Large Group SOB

January 2022 Large Group Summary of Benefits

Large Groups (101 and above)

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:

 

Related Links

Forms and Applications | Benefit Modification Brochures | Group administrator guide | Employer Connection provides resources for your clients | Network 

Show full contents

Prescription drug options

Access+ HMO Plans Summary of Benefits Optional Benefits Disclosures
Access+ HMO® Zero Admit 10 English (PDF, 1MB)
Spanish (PDF, 161KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB)
 
Access+ HMO® Zero Admit 15 English (PDF, 952KB)
Spanish (PDF, 139KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB)
Access+ HMO® Zero Admit 20 English (PDF, 1MB)
Spanish (PDF, 161KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB)
Access+ HMO® Zero Admit 30 English (PDF, 1MB)
Spanish (PDF, 161KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB)
Access+ HMO® Per Admit 10-250 English (PDF, 1MB)
Spanish (PDF, 162KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB)
Access+ HMO® Per Admit 20-250 English (PDF, 1MB)
Spanish (PDF, 161KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB)  
Access+ HMO® Per Admit 20-500 English (PDF, 1MB)
Spanish (PDF, 161KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB) 
Access+ HMO® Per Admit 25-750 English (PDF, 1MB)
Spanish (PDF, 161KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB)
Access+ HMO® Per Admit 40-1000 English (PDF, 1MB)
Spanish (PDF, 161KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB)  
Access+ HMO® Per Day 15-500 English (PDF, 1MB)
Spanish (PDF, 161KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB)
Access+ HMO® Per Day 25-750  English (PDF, 1MB)
Spanish (PDF, 161KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB)  
Access+ HMO® Facility Coinsurance
15-20%		 English (PDF, 1MB)
Spanish (PDF, 162KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB) 
Access+ HMO® Facility Coinsurance
20-20%		 English (PDF, 1MB)
Spanish (PDF, 162KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB)
Access+ HMO® Facility Coinsurance
25-25%		 English (PDF, 1MB)
Spanish (PDF, 1MB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB)

Access+ HMO® Facility Coinsurance 30-30%

 English (PDF, 1MB)
Spanish (PDF, 162KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB) 
Access+ HMO® Facility Coinsurance
40-40%		 English (PDF, 1MB)
Spanish (PDF, 162KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB)  
Access+ HMO® Zero Facility Deductible
30-20%		 English  (PDF, 1MB)
Spanish (PDF, 162KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB)  
Access+ HMO® Facility Deductible 15-10%/250 English (PDF, 1MB)
Spanish (PDF, 165KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB)
Access+ HMO® Facility Deductible 15-10%/500 English  (PDF, 1MB)
Spanish (PDF, 165KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB) 
Access+ HMO® Facility Deductible 15-10%/750 English (PDF, 1MB)
Spanish (PDF, 165KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB)
Access+ HMO® Facility Deductible
15-10%/1500		 English (PDF, 1MB)
Spanish (PDF, 165KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)
Additional infertility 95% (PDF, 110KB)

English (1.1MB)  
Access+ HMO® Facility Deductible
20-25%/1500		 English (PDF, 1MB)
Spanish (PDF, 162KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB)
Access+ HMO® Facility Deductible
30-10%/1500		 English (PDF, 1MB)
Spanish (PDF, 165KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB) 
Access+ HMO® Facility Deductible 30-30%/2000 English (PDF, 1MB)
Spanish (PDF, 165KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB)
Access+ HMO® Facility Deductible 40-40%/2000 English (PDF, 1MB)
Spanish (PDF, 165KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB)  
Access+ HMO® Facility Deductible 40-40%/5800 English (PDF, 1MB)
Spanish (PDF, 165KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB)

 

Access+ HMO SaveNet Plans Summary of Benefits Optional Benefits Disclosures
Access+ HMO® SaveNet
Zero Admit 10		 English (PDF, 1MB)
Spanish (PDF, 161KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB)
Access+ HMO® SaveNet
Zero Admit 20		 English (PDF, 1MB)
Spanish (PDF, 165KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB)  
Access+ HMO® SaveNet
Zero Admit 30		 English (PDF, 1MB)
Spanish (PDF, 161KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB)
Access+ HMO® SaveNet
Per Admit 10-250		 English (PDF, 1MB)
Spanish (PDF, 161KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB)
Access+ HMO® SaveNet
Per Admit 20-500		 English (PDF, 1MB)
Spanish (PDF, 161KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB)
Access+ HMO® SaveNet
Per Admit 25-750		 English (PDF, 1MB)
Spanish (PDF, 161KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB)
Access+ HMO® SaveNet
Per Admit 40-1000		 English (PDF, 1MB)
Spanish (PDF, 161KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB)
Access+ HMO® SaveNet
Facility Coinsurance 15-20%		 English (PDF, 1MB)
Spanish (PDF, 162KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB)
Access+ HMO® SaveNet
Facility Coinsurance 20-20%		 English (PDF, 1MB)
Spanish (PDF, 162KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB) 
Access+ HMO® SaveNet
Facility Coinsurance 25-25%		 English (PDF, 1MB)
Spanish (PDF, 162KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB)
Access+ HMO® SaveNet
Facility Coinsurance 40-40%		 English (PDF, 1MB)
Spanish (PDF, 162KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB) 
Access+ HMO® SaveNet 
Facility Deductible
15-10%/1500		 English (PDF, 1MB)
Spanish (PDF, 162KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB) 
Access+ HMO® SaveNet
Facility Deductible
20-25%/1500		 English (PDF, 1MB)
Spanish (PDF, 165KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB)
Access+ HMO® SaveNet
Facility Deductible
30-30%/2000		 English (PDF, 1MB)
Spanish (PDF, 165KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB) 
Access+ HMO® SaveNet
Facility Deductible
40-40%/2000		 English (PDF, 1MB)
Spanish (PDF, 166KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)
Additional infertility 95% (PDF, 110KB)

English (1.1MB)
Access+ HMO® SaveNet
Facility Deductible
40-40%/5800		 English (PDF, 1MB)
Spanish (PDF, 152KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB)

 

Local Access+ HMO Plans Summary of Benefits Optional Benefits Disclosures
Local Access+ HMO® Zero Admit 10

English (PDF, 1MB)
Spanish (PDF, 161KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB) 
Local Access+ HMO® Zero Admit 20 English  (PDF, 1MB)
Spanish  (PDF, 161KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB)
Local Access+ HMO® Zero Admit 30 English  (PDF, 1MB)
Spanish  (PDF, 161KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB)
Local Access+ HMO® Per Admit 10-250 English  (PDF, 1MB)
Spanish  (PDF, 161KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB) 
Local Access+ HMO® Per Admit 20-500 English  (PDF, 1MB)
Spanish  (PDF, 161KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB) 
Local Access+ HMO® Per Admit 25-750 English  (PDF, 1MB)
Spanish  (PDF, 161KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB)
Local Access+ HMO® Per Admit 40-1000 English  (PDF, 1MB)
Spanish  (PDF, 161KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB)
Local Access+ HMO® Facility Coinsurance 15-20% English  (PDF, 1MB)
Spanish  (PDF, 162KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB)
Local Access+ HMO® Facility Coinsurance 20-20% English  (PDF, 1MB)
Spanish  (PDF, 162KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB)  
Local Access+ HMO® Facility Coinsurance 25-25%

English (PDF, 1MB)
Spanish (PDF, 162KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB)
Local Access+ HMO® Facility Coinsurance 40-40% English  (PDF, 1MB)
Spanish  (PDF, 162KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB)  
Local Access+ HMO® Facility Deductible 15-10%/1500 English  (PDF, 1MB)
Spanish (PDF, 165KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB) 
Local Access+ HMO® Facility Deductible 20-25%/1500 English  (PDF, 1MB)
Spanish  (PDF, 165KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB)
Local Access+ HMO® Facility Deductible 30-30%/2000 English  (PDF, 1MB)
Spanish  (PDF, 165KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB)
Local Access+ HMO® Facility Deductible 40-40%/2000 English  (PDF, 1MB)
Spanish (PDF, 165KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB) 
Local Access+ HMO® Facility Deductible 40-40%/5800 English  (PDF, 1MB)
Spanish  (PDF,166KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB) 

 

Trio HMO Plans Summary of Benefits Optional Benefits Disclosures
Trio HMO Zero Admit 10 English (PDF, 1MB)
Spanish (PDF, 161KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB)
 
Trio HMO Zero Admit 15 English  (PDF, 1MB)
Spanish  (PDF, 161KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB)
Trio HMO Zero Admit 20 English (PDF, 1MB)
Spanish (PDF, 161KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB)
Trio HMO Zero Admit 30 English (PDF, 1MB)
Spanish (PDF, 161KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB)
Trio HMO Per Admit 10-250 English (PDF, 1MB)
Spanish (PDF, 161KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB)
Trio HMO Per Admit 20-250 English (PDF, 1MB)
Spanish (PDF, 161KB)


Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB)
Trio HMO Per Admit 20-500 English (PDF, 1MB)
Spanish (PDF, 161KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB)  
Trio HMO Per Admit 25-750 English (PDF, 1MB)
Spanish (PDF, 161KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB)
Trio HMO Per Admit 40-1000 English (PDF, 1MB)
Spanish (PDF, 161KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB)
Trio HMO Per Day 15-500 English (PDF, 1MB)
Spanish (PDF, 160KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB)
Trio HMO Per Day 25-750 English (PDF, 1MB)
Spanish (PDF, 161KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB)
Trio HMO Facility Coinsurance 15-20% English (PDF, 1MB)
Spanish (PDF, 161KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB) 
Trio HMO Facility Coinsurance 20-20% English  (PDF, 1MB)
Spanish (PDF, 161KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB)
Trio HMO Facility Coinsurance 25-25% English (PDF, 1MB)
Spanish (PDF, 161KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB) 
Trio HMO Facility Coinsurance 30-30% English (PDF, 1MB)
Spanish (PDF, 161KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB)
Trio HMO Facility Coinsurance 40-40% English (PDF, 1MB)
Spanish (PDF, 161KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB)
Trio HMO Facility Deductible 15-10%/250 English (PDF, 1MB)
Spanish (PDF, 165KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB)
Trio HMO Facility Deductible 15-10%/500

 

English (PDF, 1MB)
Spanish (PDF, 165KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB)
Trio HMO Facility Deductible 15-10%/750 English (PDF, 1MB)
Spanish (PDF, 165KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB) 
Trio HMO Facility Deductible 15-10%/1500 English (PDF, 1MB)
Spanish (PDF, 165KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB) 
Trio HMO Facility Deductible 20-25%/1500 English  (PDF, 1MB)
Spanish  (PDF, 165KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB)
Trio HMO Facility Deductible 30-10%/1500 English (PDF, 1MB)
Spanish (PDF, 165KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB) 
Trio HMO Facility Deductible 30-30%/2000 English  (PDF, 1MB)
Spanish  (PDF, 165KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB) 
Trio HMO Facility Deductible 40-40%/2000 English (PDF, 1MB)
Spanish (PDF, 165KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB)
Trio HMO Facility Deductible 40-40%/5800 English  (PDF, 1MB)
Spanish (PDF, 166KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB)
Trio HMO Zero Facility Deductible 30-20% English  (PDF, 1MB)
Spanish  (PDF, 161KB)

Chiropractic (PDF, 992KB)
Chiropractic and acupuncture (PDF, 994KB)
Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Chiropractic (PDF, 1.7MB)
Chiropractic and acupuncture (PDF, 1.7MB)
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

English (1.1MB)  

 

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, 1MB)
Spanish (PDF, 196KB)

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
Full PPO No Network Deductible 20 100/50 English (PDF, 1MB)
Spanish (PDF, 196KB)
 

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
Full PPO Combined Deductible 0-250 80/60

English (PDF, 1MB)
Spanish (PDF, 196KB)

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
Full PPO Combined Deductible 0-250 90/70

English (PDF, 1MB)
Spanish (PDF, 196KB)

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
Full PPO Combined Deductible 0-400 90/70

English (PDF, 1MB)
Spanish (PDF, 196KB)

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
Full PPO Combined Deductible 10-250 90/70

English (PDF, 1MB)
Spanish (PDF, 196KB)

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
Full PPO Combined Deductible 10-500 90/70

English (PDF, 1MB)
Spanish (PDF, 196KB)

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
Full PPO Combined Deductible 15-250 90/70 English (PDF, 1MB)
Spanish (PDF, 196KB)

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
Full PPO Combined Deductible 20-200 90/70 English (PDF, 1MB)
Spanish (PDF, 196KB)

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
Full PPO Combined Deductible 20-250 80/60 English (PDF, 1MB)
Spanish (PDF, 196KB)

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
Full PPO Combined Deductible 25-250 80/60 English (PDF, 1MB)
Spanish (PDF, 196KB)

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
Full PPO Combined Deductible 25-250 90/60 English (PDF, 1MB)
Spanish (PDF, 196KB)

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
Full PPO Combined Deductible 30-500 90/60 English (PDF, 1MB)
Spanish (PDF, 196KB)

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
Full PPO Combined Deductible 30-750 80/60 English (PDF, 1MB)
Spanish (PDF, 196KB)

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
Full PPO Combined Deductible 35-500 80/60 English (PDF, 1MB)
Spanish (PDF, 196KB)

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
Full PPO Combined Deductible Value 10-1000 90/70 English (PDF, 1MB)
Spanish (PDF, 196KB)

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
Full PPO Combined Deductible Value 15-1500 80/50 English (PDF, 1MB)
Spanish (PDF, 196KB)

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
Full PPO Combined Deductible Value 20-2000 80/50 English (PDF, 1MB)
Spanish (PDF, 196KB)

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
Full PPO Combined Deductible Value 25-2500 80/50 English (PDF, 1MB)
Spanish (PDF, 196KB)

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
Full PPO Combined Deductible Value 30-3000 80/50 English (PDF, 1MB)
Spanish (PDF, 196KB)

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
Full PPO Combined Deductible Value 40-4000 80/50 English (PDF, 1MB)
Spanish (PDF, 196KB)

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
Full PPO Combined Deductible Value 50-4500 80/50 English (PDF, 1MB)
Spanish (PDF, 196KB)

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
Full PPO Split Deductible 0-1750 80/60 English (PDF, 1MB)
Spanish (PDF, 196KB)

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
Full PPO Split Deductible 0-500 80/60 English (PDF, 1MB)
Spanish (PDF, 196KB)

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
Full PPO Split Deductible 10-250 90/70 English (PDF, 1MB)
Spanish (PDF, 196KB)

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
Full PPO Split Deductible 15-500 90/60 English (PDF, 1MB)
Spanish (PDF, 196KB)

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
Full PPO Split Deductible 20-500 80/60 English ((PDF, 47KB)
Spanish (PDF, 196KB)

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
Full PPO Split Deductible 25-750 80/60 English (PDF, 1MB)
Spanish (PDF, 196KB)

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
Full PPO Split Deductible 35-1000 80/60 English (PDF, 1MB)
Spanish (PDF, 196KB)

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
Full PPO Split Deductible 30-2000 70/50 English (PDF, 1MB)
Spanish (PDF, 196KB)

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
Full PPO Split Deductible 40-4000 70/50 English (PDF, 1MB)
Spanish (PDF, 196KB)

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)

 

 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, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 992KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
Full PPO Savings Two-Tier
Embedded Deductible 1500/2800/3000		 English (PDF, 1MB)
Spanish (PDF, 196KB)

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 992KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
Full PPO Savings Two-Tier
Embedded Deductible 1500/2800/3000 100%		 English (PDF, 1MB)
Spanish (PDF, 196KB)

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 992KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
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, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 992KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
Full PPO Savings Two-Tier
Embedded Deductible 1800/2800/3600		 English (PDF, 1MB)
Spanish (PDF, 196KB)

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 992KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
Full PPO Savings Two-Tier
Embedded Deductible 2250/2800/4500		 English (PDF, 1MB)
Spanish (PDF, 196KB)

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 992KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)
Additional infertility 95% (PDF, 109KB)

 English (PDF, 1.1MB)
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, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 992KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)

 

 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, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 992KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
Full PPO Savings Embedded Deductible 3000 English (PDF, 1MB)
Spanish (PDF, 196KB)

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 992KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
Full PPO Savings Embedded Deductible 3000 100% English (PDF, 1MB)
Spanish (PDF, 196KB)

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 992KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
Full PPO Savings Embedded Deductible 3500 English (PDF, 1MB)
Spanish (PDF, 196KB)

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 992KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
Full PPO Savings Embedded Deductible 4000

English (PDF, 1MB)
Spanish (PDF, 196KB)

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 992KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
Full PPO Savings Embedded Deductible 4400 100%

English (PDF, 1MB)
Spanish (PDF, 196KB)

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 992KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
Full PPO Savings Embedded Deductible 5500 English (PDF, 1MB)
Spanish (PDF, 196KB)

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 992KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
Full PPO Savings Embedded Deductible 6350 100% English (PDF, 1MB)
Spanish (PDF, 196KB)

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 991KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
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, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 992KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
Tandem PPO Combined Deductible
0-250 80/60		 English (PDF, 1MB)
Spanish (PDF, 196KB)

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 992KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
Tandem PPO Combined Deductible
0-250 90/70		 English (PDF, 1MB)
Spanish (PDF, 196KB)

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 992KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
Tandem PPO Combined Deductible
0-400 90/70		 English (PDF, 1MB)
Spanish (PDF, 196KB)

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 992KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
Tandem PPO Combined Deductible
10-250 90/70		 English (PDF, 1MB)
Spanish (PDF, 196KB)

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 992KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
Tandem PPO Combined Deductible
15-250 90/70		 English (PDF, 1MB)
Spanish (PDF, 196KB)

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 992KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
Tandem PPO Combined Deductible
20-200 90/70		 English (PDF, 1MB)
Spanish (PDF, 196KB)

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 992KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
Tandem PPO Combined Deductible
20-250 80/60		 English (PDF, 1MB)
Spanish (PDF, 196KB)

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 992KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
Tandem PPO Combined Deductible
25-250 80/60		 English (PDF, 1MB)
Spanish (PDF, 196KB)

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 992KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
Tandem PPO Combined Deductible 25-250 90/60 English (PDF, 1MB)
Spanish (PDF, 196KB)

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 992KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
Tandem PPO Combined Deductible
Value 10-1000 90/70		 English (PDF, 1MB)
Spanish (PDF, 196KB)

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 992KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
Tandem PPO Split Deductible
0-1750 80/60		 English (PDF, 1MB)
Spanish (PDF, 196KB)

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 992KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
Tandem PPO Split Deductible 0-500 80/60 English (PDF, 1MB)
Spanish (PDF, 196KB)

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 992KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
Tandem PPO Split Deductible 10-250 90/70 English (PDF, 1MB)
Spanish (PDF, 196KB)

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 992KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
Tandem PPO Split Deductible 20-500 80/60 English (PDF, 1MB)
Spanish (PDF, 196KB)

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 992KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
Tandem PPO Split Deductible 25-750 80/60 English (PDF, 1MB)
Spanish (PDF, 196KB)

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 992KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
Tandem PPO Split Deductible 30-1500 80/50 English (PDF, 1MB)
Spanish (PDF, 196KB)

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 992KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
Tandem PPO Split Deductible 35-1000 80/60 English (PDF, 1MB)
Spanish (PDF, 196KB)

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 992KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
Tandem PPO Split Deductible 40-3000 70/50 English (PDF, 1MB)
Spanish (PDF, 196KB)

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 992KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
Tandem PPO Savings Plans Summary of Benefits Optional Benefits  Disclosures
Tandem PPO Savings Embedded Deductible 3000 English (PDF, 1MB)
Spanish (PDF, 196KB)

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 992KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
Tandem PPO Savings Embedded Deductible 4425 English (PDF, 1MB)
Spanish (PDF, 196KB)

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 992KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)
Tandem PPO Savings Embedded Deductible 6350 100% English (PDF, 1MB)
Spanish (PDF, 196KB)

Hearing aid (PDF, 987KB)
Base infertility 50% (PDF, 991KB)
Additional infertility 50% (PDF, 991KB)
Additional infertility 80% (PDF, 992KB)
Additional infertility 95% (PDF, 991KB)

Spanish
Hearing aid (PDF, 1.7MB)
Base infertility 50% (PDF, 1.7MB)
Additional infertility 50% (PDF, 1.7MB)
Additional infertility 80% (PDF, 1.7MB)
Additional infertility 95% (PDF, 1.7MB)

 English (PDF, 1.1MB)

 

Active Choice PPO Plans Summary of Benefits Optional Benefits  Disclosures
Active Choice® 500 80/50 English (PDF, 882KB)
Spanish (PDF, 916KB)

Hearing aid (PDF, 9724KB)
Base infertility 50% (PDF, 727KB)
Additional infertility 50% (PDF, 727KB)
Additional infertility 80% (PDF, 728KB)
Additional infertility 95% (PDF, 728KB)

Spanish
Hearing aid (PDF, 758KB)
Base infertility 50% (PDF, 772KB)
Additional infertility 50% (PDF, 771KB)
Additional infertility 80% (PDF, 772KB)
Additional infertility 95% (PDF, 772KB)

 English (PDF, 1.3MB)
Active Choice® 500 80/50 
1500 Deductible		 English (PDF, 882KB)
Spanish (PDF, 994KB)

Hearing aid (PDF, 9724KB)
Base infertility 50% (PDF, 727KB)
Additional infertility 50% (PDF, 727KB)
Additional infertility 80% (PDF, 728KB)
Additional infertility 95% (PDF, 728KB)

Spanish
Hearing aid (PDF, 758KB)
Base infertility 50% (PDF, 772KB)
Additional infertility 50% (PDF, 771KB)
Additional infertility 80% (PDF, 772KB)
Additional infertility 95% (PDF, 772KB)

 English (PDF, 1.3MB)
Active Choice® 750 70/50 English (PDF, 882KB)
Spanish (PDF, 994KB)

Hearing aid (PDF, 9724KB)
Base infertility 50% (PDF, 727KB)
Additional infertility 50% (PDF, 727KB)
Additional infertility 80% (PDF, 728KB)
Additional infertility 95% (PDF, 728KB)

Spanish
Hearing aid (PDF, 758KB)
Base infertility 50% (PDF, 772KB)
Additional infertility 50% (PDF, 771KB)
Additional infertility 80% (PDF, 772KB)
Additional infertility 95% (PDF, 772KB)

 English (PDF, 1.3B)
Active Choice® 750 70/50 1000 Deductible English (PDF, 882KB)
Spanish (PDF, 919KB)

Hearing aid (PDF, 9724KB)
Base infertility 50% (PDF, 727KB)
Additional infertility 50% (PDF, 727KB)
Additional infertility 80% (PDF, 728KB)
Additional infertility 95% (PDF, 728KB)

Spanish
Hearing aid (PDF, 758KB)
Base infertility 50% (PDF, 772KB)
Additional infertility 50% (PDF, 771KB)
Additional infertility 80% (PDF, 772KB)
Additional infertility 95% (PDF, 772KB)

 English (PDF, 1.3MB)
Active Choice® 750 80/60 English (PDF, 882KB)
Spanish (PDF, 984KB)

Hearing aid (PDF, 9724KB)
Base infertility 50% (PDF, 727KB)
Additional infertility 50% (PDF, 727KB)
Additional infertility 80% (PDF, 728KB)
Additional infertility 95% (PDF, 728KB)

Spanish
Hearing aid (PDF, 758KB)
Base infertility 50% (PDF, 772KB)
Additional infertility 50% (PDF, 771KB)
Additional infertility 80% (PDF, 772KB)
Additional infertility 95% (PDF, 772KB)

 English (PDF, 1.3MB)

 

Active Choice PPO Classic/Plus Plans Summary of Benefits Optional Benefits  Disclosures
Active Choice® Plus 300 20 80/60 English (PDF, 882KB)
Spanish (PDF, 916KB)

Hearing aid (PDF, 9724KB)
Base infertility 50% (PDF, 727KB)
Additional infertility 50% (PDF, 727KB)
Additional infertility 80% (PDF, 728KB)
Additional infertility 95% (PDF, 728KB)

Spanish
Hearing aid (PDF, 758KB)
Base infertility 50% (PDF, 772KB)
Additional infertility 50% (PDF, 771KB)
Additional infertility 80% (PDF, 772KB)
Additional infertility 95%