Summary of Benefits 2022

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).

When providing the Summary of Benefits to an applicant or Blue Shield member, you must also include a Notice of Language Assistance (PDF, 1.1 MB).

In addition, the Summary of Benefits and Coverage (SBC) Forms, provide your clients with an easy-to-understand overview of what our plans for groups of 101 and above cover. You can download SBC Forms and other resources for these plans:

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

HMO plans

Prescription drug options

Access+ HMO plans	Summary of Benefits	Optional benefits	Disclosures
Access+ HMO® Zero Admit 10	English (PDF, 1 MB) Spanish (PDF, 161 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Access+ HMO® Zero Admit 15	English (PDF, 952 KB) Spanish (PDF, 139 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Access+ HMO® Zero Admit 20	English (PDF, 1 MB) Spanish (PDF, 161 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Addinal infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Access+ HMO® Zero Admit 30	English (PDF, 1 MB) Spanish (PDF, 161 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Access+ HMO® Per Admit 10-250	English (PDF, 1 MB) Spanish (PDF, 162 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Access+ HMO® Per Admit 20-250	English (PDF, 1 MB) Spanish (PDF, 161 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Access+ HMO® Per Admit 20-500	English (PDF, 1 MB) Spanish (PDF, 161 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Access+ HMO® Per Admit 25-750	English (PDF, 1 MB) Spanish (PDF, 161 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Access+ HMO® Per Admit 40-1000	English (PDF, 1 MB) Spanish (PDF, 161 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Access+ HMO® Per Day 15-500	English (PDF, 1 MB) Spanish (PDF, 161 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Access+ HMO® Per Day 25-750	English (PDF, 1 MB) Spanish (PDF, 161 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Access+ HMO® Facility Coinsurance 15-20%	English (PDF, 1 MB) Spanish (PDF, 162 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Access+ HMO® Facility Coinsurance 20-20%	English (PDF, 1 MB) Spanish (PDF, 162 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Access+ HMO® Facility Coinsurance 25-25%	English (PDF, 1 MB) Spanish (PDF, 1 MB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Access+ HMO® Facility Coinsurance 30-30%	English (PDF, 1 MB) Spanish (PDF, 162 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Access+ HMO® Facility Coinsurance 40-40%	English (PDF, 1 MB) Spanish (PDF, 162 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Access+ HMO® Zero Facility Deductible 30-20%	English (PDF, 1 MB) Spanish (PDF, 162 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Access+ HMO® Facility Deductible 15-10%/250	English (PDF, 1 MB) Spanish (PDF, 165 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Access+ HMO® Facility Deductible 15-10%/500	English (PDF, 1 MB) Spanish (PDF, 165 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Access+ HMO® Facility Deductible 15-10%/750	English (PDF, 1 MB) Spanish (PDF, 165 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Access+ HMO® Facility Deductible 15-10%/1500	English (PDF, 1 MB) Spanish (PDF, 165 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Access+ HMO® Facility Deductible 20-25%/1500	English (PDF, 1 MB) Spanish (PDF, 162 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Access+ HMO® Facility Deductible 30-10%/1500	English (PDF, 1 MB) Spanish (PDF, 165 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Access+ HMO® Facility Deductible 30-30%/2000	English (PDF, 1 MB) Spanish (PDF, 165 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Access+ HMO® Facility Deductible 40-40%/2000	English (PDF, 1 MB) Spanish (PDF, 165 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Access+ HMO® Facility Deductible 40-40%/5800	English (PDF, 1 MB) Spanish (PDF, 165 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)

Access+ HMO SaveNet plans	Summary of Benefits	Optional benefits	Disclosures
Access+ HMO® SaveNet Zero Admit 10	English (PDF, 1 MB) Spanish (PDF, 161 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Access+ HMO® SaveNet Zero Admit 20	English (PDF, 1 MB) Spanish (PDF, 165 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Access+ HMO® SaveNet Zero Admit 30	English (PDF, 1 MB) Spanish (PDF, 161 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Access+ HMO® SaveNet Per Admit 10-250	English (PDF, 1 MB) Spanish (PDF, 161 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Access+ HMO® SaveNet Per Admit 20-500	English (PDF, 1 MB) Spanish (PDF, 161 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Access+ HMO® SaveNet Per Admit 25-750	English (PDF, 1 MB) Spanish (PDF, 161 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Access+ HMO® SaveNet Per Admit 40-1000	English (PDF, 1 MB) Spanish (PDF, 161 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Access+ HMO® SaveNet Facility Coinsurance 15-20%	English (PDF, 1 MB) Spanish (PDF, 162 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Access+ HMO® SaveNet Facility Coinsurance 20-20%	English (PDF, 1 MB) Spanish (PDF, 162 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Access+ HMO® SaveNet Facility Coinsurance 25-25%	English (PDF, 1 MB) Spanish (PDF, 162 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Access+ HMO® SaveNet Facility Coinsurance 40-40%	English (PDF, 1 MB) Spanish (PDF, 162 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Access+ HMO® SaveNet Facility Deductible 15-10%/1500	English (PDF, 1 MB) Spanish (PDF, 162 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Access+ HMO® SaveNet Facility Deductible 20-25%/1500	English (PDF, 1 MB) Spanish (PDF, 165 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Access+ HMO® SaveNet Facility Deductible 30-30%/2000	English (PDF, 1 MB) Spanish (PDF, 165 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Access+ HMO® SaveNet Facility Deductible 40-40%/2000	English (PDF, 1 MB) Spanish (PDF, 166 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Access+ HMO® SaveNet Facility Deductible 40-40%/5800	English (PDF, 1 MB) Spanish (PDF, 152 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)

Local Access+ HMO plans	Summary of Benefits	Optional benefits	Disclosures
Local Access+ HMO® Zero Admit 10	English (PDF, 1 MB) Spanish (PDF, 161 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Local Access+ HMO® Zero Admit 20	English (PDF, 1 MB) Spanish (PDF, 161 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Local Access+ HMO® Zero Admit 30	English (PDF, 1 MB) Spanish (PDF, 161 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Local Access+ HMO® Per Admit 10-250	English (PDF, 1 MB) Spanish (PDF, 161 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Local Access+ HMO® Per Admit 20-500	English (PDF, 1 MB) Spanish (PDF, 161 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Local Access+ HMO® Per Admit 25-750	English (PDF, 1 MB) Spanish (PDF, 161 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Local Access+ HMO® Per Admit 40-1000	English (PDF, 1 MB) Spanish (PDF, 161 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Local Access+ HMO® Facility Coinsurance 15-20%	English (PDF, 1 MB) Spanish (PDF, 162 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Local Access+ HMO® Facility Coinsurance 20-20%	English (PDF, 1 MB) Spanish (PDF, 162 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Local Access+ HMO® Facility Coinsurance 25-25%	English (PDF, 1 MB) Spanish (PDF, 162 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Local Access+ HMO® Facility Coinsurance 40-40%	English (PDF, 1 MB) Spanish (PDF, 162 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Local Access+ HMO® Facility Deductible 15-10%/1500	English (PDF, 1 MB) Spanish (PDF, 165 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Local Access+ HMO® Facility Deductible 20-25%/1500	English (PDF, 1 MB) Spanish (PDF, 165 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Local Access+ HMO® Facility Deductible 30-30%/2000	English (PDF, 1 MB) Spanish (PDF, 165 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Local Access+ HMO® Facility Deductible 40-40%/2000	English (PDF, 1 MB) Spanish (PDF, 165 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Local Access+ HMO® Facility Deductible 40-40%/5800	English (PDF, 1 MB) Spanish (PDF, 166 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)

Trio HMO plans	Summary of Benefits	Optional benefits	Disclosures
Trio HMO Zero Admit 10	English (PDF, 1 MB) Spanish (PDF, 161 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Trio HMO Zero Admit 15	English (PDF, 1 MB) Spanish (PDF, 161 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Trio HMO Zero Admit 20	English (PDF, 1 MB) Spanish (PDF, 161 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Trio HMO Zero Admit 30	English (PDF, 1 MB) Spanish (PDF, 161 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Trio HMO Per Admit 10-250	English (PDF, 1 MB) Spanish (PDF, 161 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Trio HMO Per Admit 20-250	English (PDF, 1 MB) Spanish (PDF, 161 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Trio HMO Per Admit 20-500	English (PDF, 1 MB) Spanish (PDF, 161 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Trio HMO Per Admit 25-750	English (PDF, 1 MB) Spanish (PDF, 161 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Trio HMO Per Admit 40-1000	English (PDF, 1 MB) Spanish (PDF, 161 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Trio HMO Per Day 15-500	English (PDF, 1 MB) Spanish (PDF, 160 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Trio HMO Per Day 25-750	English (PDF, 1 MB) Spanish (PDF, 161 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Trio HMO Facility Coinsurance 15-20%	English (PDF, 1 MB) Spanish (PDF, 161 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Trio HMO Facility Coinsurance 20-20%	English (PDF, 1 MB) Spanish (PDF, 161 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Trio HMO Facility Coinsurance 25-25%	English (PDF, 1 MB) Spanish (PDF, 161 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Trio HMO Facility Coinsurance 30-30%	English (PDF, 1 MB) Spanish (PDF, 161 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Trio HMO Facility Coinsurance 40-40%	English (PDF, 1 MB) Spanish (PDF, 161 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Trio HMO Facility Deductible 15-10%/250	English (PDF, 1 MB) Spanish (PDF, 165 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Trio HMO Facility Deductible 15-10%/500	English (PDF, 1 MB) Spanish (PDF, 165 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Trio HMO Facility Deductible 15-10%/750	English (PDF, 1 MB) Spanish (PDF, 165 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Trio HMO Facility Deductible 15-10%/1500	English (PDF, 1 MB) Spanish (PDF, 165 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Trio HMO Facility Deductible 20-25%/1500	English (PDF, 1 MB) Spanish (PDF, 165 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Trio HMO Facility Deductible 30-10%/1500	English (PDF, 1 MB) Spanish (PDF, 165 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Trio HMO Facility Deductible 30-30%/2000	English (PDF, 1 MB) Spanish (PDF, 165 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Trio HMO Facility Deductible 40-40%/2000	English (PDF, 1 MB) Spanish (PDF, 165 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Trio HMO Facility Deductible 40-40%/5800	English (PDF, 1 MB) Spanish (PDF, 166 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Trio HMO Zero Facility Deductible 30-20%	English (PDF, 1 MB) Spanish (PDF, 161 KB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)

PPO plans

Prescription drug options

Full PPO plans	Summary of Benefits	Optional benefits	Disclosures
Full PPO No Network Deductible 10 100/50	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Full PPO No Network Deductible 20 100/50	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Full PPO Combined Deductible 0-250 80/60	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Full PPO Combined Deductible 0-250 90/70	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Full PPO Combined Deductible 0-400 90/70	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Full PPO Combined Deductible 10-250 90/70	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Full PPO Combined Deductible 10-500 90/70	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Full PPO Combined Deductible 15-250 90/70	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Full PPO Combined Deductible 20-200 90/70	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Full PPO Combined Deductible 20-250 80/60	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Full PPO Combined Deductible 25-250 80/60	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Full PPO Combined Deductible 25-250 90/60	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Full PPO Combined Deductible 30-500 90/60	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Full PPO Combined Deductible 30-750 80/60	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Full PPO Combined Deductible 35-500 80/60	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Full PPO Combined Deductible Value 10-1000 90/70	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Full PPO Combined Deductible Value 15-1500 80/50	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Full PPO Combined Deductible Value 20-2000 80/50	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Full PPO Combined Deductible Value 25-2500 80/50	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Full PPO Combined Deductible Value 30-3000 80/50	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Full PPO Combined Deductible Value 40-4000 80/50	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Full PPO Combined Deductible Value 50-4500 80/50	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Full PPO Split Deductible 0-1750 80/60	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Full PPO Split Deductible 0-500 80/60	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Full PPO Split Deductible 10-250 90/70	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Full PPO Split Deductible 15-500 90/60	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Full PPO Split Deductible 20-500 80/60	English ((PDF, 47 KB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Full PPO Split Deductible 25-750 80/60	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Full PPO Split Deductible 35-1000 80/60	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Full PPO Split Deductible 30-2000 70/50	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Full PPO Split Deductible 40-4000 70/50	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)

Full PPO Savings Two-Tier plans	Summary of Benefits	Optional benefits	Disclosures
Full PPO Savings Two-Tier Embedded Deductible 1400/2800/2800	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 992 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Full PPO Savings Two-Tier Embedded Deductible 1500/2800/3000	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 992 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Full PPO Savings Two-Tier Embedded Deductible 1500/2800/3000 100%	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 992 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Full PPO Savings Two-Tier Embedded Deductible 1500/2800/3000 with $0 HDHP Preventive Drug Benefit	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 992 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Full PPO Savings Two-Tier Embedded Deductible 1800/2800/3600	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 992 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Full PPO Savings Two-Tier Embedded Deductible 2250/2800/4500	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 992 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Full PPO Savings Two-Tier Embedded Deductible 2250/2800/4500 with $0 HDHP Preventive Drug Benefit	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 992 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)

Full PPO Savings plans	Summary of Benefits	Optional benefits	Disclosures
Full PPO Savings Embedded Deductible 2800	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 992 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Full PPO Savings Embedded Deductible 3000	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 992 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Full PPO Savings Embedded Deductible 3000 100%	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 992 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Full PPO Savings Embedded Deductible 3500	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 992 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Full PPO Savings Embedded Deductible 4000	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 992 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Full PPO Savings Embedded Deductible 4400 100%	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 992 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Full PPO Savings Embedded Deductible 5500	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 992 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Full PPO Savings Embedded Deductible 6350 100%	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 992 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)

Tandem PPO plans	Summary of Benefits	Optional benefits	Disclosures
Tandem PPO No Network Deductible 10 100/50	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 992 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Tandem PPO Combined Deductible 0-250 80/60	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 992 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Tandem PPO Combined Deductible 0-250 90/70	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 992 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Tandem PPO Combined Deductible 0-400 90/70	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 992 KB) Additional infertility 95%> (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Tandem PPO Combined Deductible 10-250 90/70	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 992 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Tandem PPO Combined Deductible 15-250 90/70	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 992 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Tandem PPO Combined Deductible 20-200 90/70	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 992 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Tandem PPO Combined Deductible 20-250 80/60	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 992 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Tandem PPO Combined Deductible 25-250 80/60	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 992 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Tandem PPO Combined Deductible 25-250 90/60	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 992 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Tandem PPO Combined Deductible Value 10-1000 90/70	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 992 KB) Additional infertility 95% (PDF, 991 KB)> Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Tandem PPO Split Deductible 0-1750 80/60	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 992 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Tandem PPO Split Deductible 0-500 80/60	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 992 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Tandem PPO Split Deductible 10-250 90/70	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 992 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Tandem PPO Split Deductible 20-500 80/60	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 992 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Tandem PPO Split Deductible 25-750 80/60	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 992 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Tandem PPO Split Deductible 30-1500 80/50	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 992 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Tandem PPO Split Deductible 35-1000 80/60	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 992 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Tandem PPO Split Deductible 40-3000 70/50	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 992 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)

Tandem PPO Savings plans	Summary of Benefits	Optional benefits	Disclosures
Tandem PPO Savings Embedded Deductible 3000	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 992 KB) Additional infertility 95%> (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Tandem PPO Savings Embedded Deductible 4425	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 992 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Tandem PPO Savings Embedded Deductible 6350 100%	English (PDF, 1 MB) Spanish (PDF, 196 KB)	English Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 992 KB) Additional infertility 95% (PDF, 991 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)

Tandem PPO Savings plans

Summary of Benefits

Optional benefits

Disclosures

Tandem PPO Savings Embedded Deductible 3000

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

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

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

English (PDF, 1.1 MB)

Tandem PPO Savings Embedded Deductible 4425

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

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

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

English (PDF, 1.1 MB)

Tandem PPO Savings Embedded Deductible 6350 100%

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

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

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

English (PDF, 1.1 MB)

Active Choice PPO plans	Summary of Benefits	Optional benefits	Disclosures
Active Choice® 500 80/50	English (PDF, 882 KB) Spanish (PDF, 916 KB)	English Hearing aid (PDF, 974 KB) Base infertility 50% (PDF, 727 KB) Additional infertility 50% (PDF, 727 KB) Additional infertility 80% (PDF, 728 KB) Additional infertility 95% (PDF, 728 KB) Spanish Hearing aid (PDF, 758 KB) Base infertility 50% (PDF, 772 KB) Additional infertility 50% (PDF, 771 KB) Additional infertility 80% (PDF, 772 KB) Additional infertility 95% (PDF, 772 KB)	English (PDF, 1.3 MB)
Active Choice® 500 80/50 1500 Deductible	English (PDF, 882 KB) Spanish (PDF, 994 KB)	English Hearing aid (PDF, 974 KB) Base infertility 50% (PDF, 727 KB) Additional infertility 50% (PDF, 727 KB) Additional infertility 80% (PDF, 728 KB) Additional infertility 95% (PDF, 728 KB) Spanish Hearing aid (PDF, 758 KB) Base infertility 50% (PDF, 772 KB) Additional infertility 50% (PDF, 771 KB) Additional infertility 80% (PDF, 772 KB) Additional infertility 95% (PDF, 772 KB)	English (PDF, 1.3 MB)
Active Choice® 750 70/50	English (PDF, 882 KB) Spanish (PDF, 994 KB)	English Hearing aid (PDF, 974 KB) Base infertility 50% (PDF, 727 KB) Additional infertility 50% (PDF, 727 KB) Additional infertility 80% (PDF, 728 KB) Additional infertility 95% (PDF, 728 KB) Spanish Hearing aid (PDF, 758 KB) Base infertility 50% (PDF, 772 KB) Additional infertility 50% (PDF, 771 KB) Additional infertility 80% (PDF, 772 KB) Additional infertility 95% (PDF, 772 KB)	English (PDF, 1.3 MB)
Active Choice® 750 70/50 1000 Deductible	English (PDF, 882 KB) Spanish (PDF, 919 KB)	English Hearing aid (PDF, 974 KB) Base infertility 50% (PDF, 727 KB) Additional infertility 50% (PDF, 727 KB) Additional infertility 80% (PDF, 728 KB) Additional infertility 95% (PDF, 728 KB) Spanish Hearing aid (PDF, 758 KB) Base infertility 50% (PDF, 772 KB) Additional infertility 50% (PDF, 771 KB) Additional infertility 80% (PDF, 772 KB) Additional infertility 95% (PDF, 772 KB)	English (PDF, 1.3 MB)
Active Choice® 750 80/60	English (PDF, 882 KB) Spanish (PDF, 984 KB)	English Hearing aid (PDF, 974 KB) Base infertility 50% (PDF, 727 KB) Additional infertility 50% (PDF, 727 KB) Additional infertility 80% (PDF, 728 KB) Additional infertility 95% (PDF, 728 KB) Spanish Hearing aid (PDF, 758 KB) Base infertility 50% (PDF, 772 KB) Additional infertility 50% (PDF, 771 KB) Additional infertility 80% (PDF, 772 KB) Additional infertility 95% (PDF, 772 KB)	English (PDF, 1.3 MB)

Active Choice PPO Classic/Plus plans	Summary of Benefits	Optional benefits	Disclosures
Active Choice® Plus 300 20 80/60	English (PDF, 882 KB) Spanish (PDF, 916 KB)	English Hearing aid (PDF, 9724 KB) Base infertility 50% (PDF, 727 KB) Additional infertility 50% (PDF, 727 KB) Additional infertility 80% (PDF, 728 KB) Additional infertility 95% (PDF, 728 KB) Spanish Hearing aid (PDF, 758 KB) Base infertility 50% (PDF, 772 KB) Additional infertility 50% (PDF, 771 KB) Additional infertility 80% (PDF, 772 KB) Additional infertility 95% (PDF, 772 KB)	English (PDF, 1.1 MB)
Active Choice® Plus 300 80/60	English (PDF, 882 KB) Spanish (PDF, 994 KB)	English Hearing aid (PDF, 974 KB) Base infertility 50% (PDF, 727 KB) Additional infertility 50% (PDF, 727 KB) Additional infertility 80% (PDF, 728 KB) Additional infertility 95% (PDF, 728 KB) Spanish Hearing aid (PDF, 758 KB) Base infertility 50% (PDF, 772 KB) Additional infertility 50% (PDF, 771 KB) Additional infertility 80% (PDF, 772 KB) Additional infertility 95% (PDF, 772 KB)	English (PDF, 1.1 MB)
Active Choice® Plus 1000 20 80/60	English (PDF, 882 KB) Spanish (PDF, 994 KB)	English Hearing aid (PDF, 974 KB) Base infertility 50% (PDF, 727 KB) Additional infertility 50% (PDF, 727 KB) Additional infertility 80% (PDF, 728 KB) Additional infertility 95% (PDF, 728 KB) Spanish Hearing aid (PDF, 758 KB) Base infertility 50% (PDF, 772 KB) Additional infertility 50% (PDF, 771 KB) Additional infertility 80% (PDF, 772 KB) Additional infertility 95% (PDF, 772 KB)	English (PDF, 1.1 MB)
Active Choice® Plus 1000 80/60	English (PDF, 882 KB) Spanish (PDF, 919 KB)	English Hearing aid (PDF, 974 KB) Base infertility 50% (PDF, 727 KB) Additional infertility 50% (PDF, 727 KB) Additional infertility 80% (PDF, 728 KB) Additional infertility 95% (PDF, 728 KB) Spanish Hearing aid (PDF, 758 KB) Base infertility 50% (PDF, 772 KB) Additional infertility 50% (PDF, 771 KB) Additional infertility 80% (PDF, 772 KB) Additional infertility 95% (PDF, 772 KB)	English (PDF, 1.1 MB)
Active Choice® Classic 600 80/50	English (PDF, 882 KB) Spanish (PDF, 984 KB)	English Hearing aid (PDF, 974 KB) Base infertility 50% (PDF, 727 KB) Additional infertility 50% (PDF, 727 KB) Additional infertility 80% (PDF, 728 KB) Additional infertility 95% (PDF, 728 KB) Spanish Hearing aid (PDF, 758 KB) Base infertility 50% (PDF, 772 KB) Additional infertility 50% (PDF, 771 KB) Additional infertility 80% (PDF, 772 KB) Additional infertility 95% (PDF, 772 KB)	English (PDF, 1.1 MB)
Active Choice® Classic 850 70/50 1000 Deductible	English (PDF, 882 KB) Spanish (PDF, 984 KB)	English Hearing aid (PDF, 974 KB) Base infertility 50% (PDF, 727 KB) Additional infertility 50% (PDF, 727 KB) Additional infertility 80% (PDF, 728 KB) Additional infertility 95% (PDF, 728 KB) Spanish Hearing aid (PDF, 758 KB) Base infertility 50% (PDF, 772 KB) Additional infertility 50% (PDF, 771 KB) Additional infertility 80% (PDF, 772 KB) Additional infertility 95% (PDF, 772 KB)	English (PDF, 1.1 MB)
Active Choice® Classic 850 80/60	English (PDF, 882 KB) Spanish (PDF, 984 KB)	English Hearing aid (PDF, 974 KB) Base infertility 50% (PDF, 727 KB) Additional infertility 50% (PDF, 727 KB) Additional infertility 80% (PDF, 728 KB) Additional infertility 95% (PDF, 728 KB) Spanish Hearing aid (PDF, 758 KB) Base infertility 50% (PDF, 772 KB) Additional infertility 50% (PDF, 771 KB) Additional infertility 80% (PDF, 772 KB) Additional infertility 95% (PDF, 772 KB)	English (PDF, 1.1 MB)

Not marketed PPO plans*	Summary of Benefits	Optional benefits	Disclosures
Shield Spectrum PPO^SM 250-90/70 Standard	English (PDF, 1.1 MB) Spanish (PDF, 273 KB)	English Hearing aid (PDF, 750 KB) Base infertility 50% (PDF, 727 KB) Additional infertility 50% (PDF, 727 KB) Additional infertility 80% (PDF, 728 KB) Additional infertility 95% (PDF, 728 KB) Spanish Hearing aid (PDF, 758 KB) Base infertility 50% (PDF, 772 KB) Additional infertility 50% (PDF, 771 KB) Additional infertility 80% (PDF, 772 KB) Additional infertility 95% (PDF, 772 KB)	English (PDF, 1.1 MB)

Not marketed PPO plans*

Summary of Benefits

Optional benefits

Disclosures

Shield Spectrum PPO^SM 250-90/70 Standard

English (PDF, 1.1 MB)
Spanish (PDF, 273 KB)

English
Hearing aid (PDF, 750 KB)
Base infertility 50% (PDF, 727 KB)
Additional infertility 50% (PDF, 727 KB)
Additional infertility 80% (PDF, 728 KB)
Additional infertility 95% (PDF, 728 KB)

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

English (PDF, 1.1 MB)

Added Advantage Point of Service Plans

Added Advantage POS^SM plans	Summary of Benefits	Optional benefits	Disclosures
Added Advantage POS^SM 300-100/90/70	English (PDF, 1.1 MB) Spanish (PDF, 1.9 MB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.2 MB)
Added Advantage POS^SM 500-100/80/60	English (PDF, 1.1 MB) Spanish (PDF, 1.9 MB)	English Chiropractic (PDF, 992 KB) Chiropractic and acupuncture (PDF, 994 KB) Hearing aid (PDF, 987 KB) Base infertility 50% (PDF, 991 KB) Additional infertility 50% (PDF, 991 KB) Additional infertility 80% (PDF, 991 KB) Additional infertility 95% (PDF, 991 KB) Spanish Chiropractic (PDF, 1.7 MB) Chiropractic and acupuncture (PDF, 1.7 MB) Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.2 MB)

Added Advantage POS^SM plans

Summary of Benefits

Optional benefits

Disclosures

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

English (PDF, 1.1 MB)
Spanish (PDF, 1.9 MB)

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

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

English (PDF, 1.2 MB)

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

English (PDF, 1.1 MB)
Spanish (PDF, 1.9 MB)

English (PDF, 1.2 MB)

EPO plans

Prescription drug options

Full EPO plans	Summary of Benefits	Optional benefits	Disclosures
Full EPO Zero Admit 20	English (PDF, 1 MB) Spanish (PDF, 1.7 MB)	English Hearing aid (PDF, 990 KB) Base infertility 50% (PDF, 994 KB) Additional infertility 50% (PDF, 994 KB) Additional infertility 80% (PDF, 994 KB) Additional infertility 95% (PDF, 994 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Full EPO Zero Admit 30	English (PDF, 1 MB) Spanish (PDF, 1.7 MB)	English Hearing aid (PDF, 990 KB) Base infertility 50% (PDF, 994 KB) Additional infertility 50% (PDF, 994 KB) Additional infertility 80% (PDF, 994 KB) Additional infertility 95% (PDF, 994 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Full EPO Per Admit 10-250	English (PDF, 1 MB) Spanish (PDF, 1.7 MB)	English Hearing aid (PDF, 990 KB) Base infertility 50% (PDF, 994 KB) Additional infertility 50% (PDF, 994 KB) Additional infertility 80% (PDF, 994 KB) Additional infertility 95% (PDF, 994 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Full EPO Facility Coinsurance 20-20%	English (PDF, 1 MB) Spanish (PDF, 1.7 MB)	English Hearing aid (PDF, 990 KB) Base infertility 50% (PDF, 994 KB) Additional infertility 50% (PDF, 994 KB) Additional infertility 80% (PDF, 994 KB) Additional infertility 95% (PDF, 994 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Full EPO 25-1500 80%	English (PDF, 1 MB) Spanish (PDF, 1.7 MB)	English Hearing aid (PDF, 990 KB) Base infertility 50% (PDF, 994 KB) Additional infertility 50% (PDF, 994 KB) Additional infertility 80% (PDF, 994 KB) Additional infertility 95% (PDF, 994 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Full EPO 25-2500 80%	English (PDF, 1 MB) Spanish (PDF, 1.7 MB)	English Hearing aid (PDF, 990 KB) Base infertility 50% (PDF, 994 KB) Additional infertility 50% (PDF, 994 KB) Additional infertility 80% (PDF, 994 KB) Additional infertility 95% (PDF, 994 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)

Tandem EPO plans	Summary of Benefits	Optional benefits	Disclosures
Tandem EPO Zero Admit 20	English (PDF, 977 KB) Spanish (PDF, 169 KB)	English Hearing aid (PDF, 990 KB) Base infertility 50% (PDF, 994 KB) Additional infertility 50% (PDF, 994 KB) Additional infertility 80% (PDF, 994 KB) Additional infertility 95% (PDF, 994 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Tandem EPO Zero Admit 30	English (PDF, 977 KB) Spanish (PDF, 169 KB)	English Hearing aid (PDF, 990 KB) Base infertility 50% (PDF, 994 KB) Additional infertility 50% (PDF, 994 KB) Additional infertility 80% (PDF, 994 KB) Additional infertility 95% (PDF, 994 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Tandem EPO Per Admit 10-250	English (PDF, 977 KB) Spanish (PDF, 170 KB)	English Hearing aid (PDF, 990 KB) Base infertility 50% (PDF, 994 KB) Additional infertility 50% (PDF, 994 KB) Additional infertility 80% (PDF, 994 KB) Additional infertility 95% (PDF, 994 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Tandem EPO Facility Coinsurance 20-20%	English (PDF, 977 KB) Spanish (PDF, 170 KB)	English Hearing aid (PDF, 990 KB) Base infertility 50% (PDF, 994 KB) Additional infertility 50% (PDF, 994 KB) Additional infertility 80% (PDF, 994 KB) Additional infertility 95% (PDF, 994 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Tandem EPO 25-1500 80%	English (PDF, 1 MB) Spanish (PDF, 1.7 MB)	English Hearing aid (PDF, 990 KB) Base infertility 50% (PDF, 994 KB) Additional infertility 50% (PDF, 994 KB) Additional infertility 80% (PDF, 994 KB) Additional infertility 95% (PDF, 994 KB) Spanish Hearing aid (PDF, 1.7MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)
Tandem EPO 25-2500 80%	English (PDF, 1 MB) Spanish (PDF, 1.7 MB)	English Hearing aid (PDF, 990 KB) Base infertility 50% (PDF, 994 KB) Additional infertility 50% (PDF, 994 KB) Additional infertility 80% (PDF, 994 KB) Additional infertility 95% (PDF, 994 KB) Spanish Hearing aid (PDF, 1.7 MB) Base infertility 50% (PDF, 1.7 MB) Additional infertility 50% (PDF, 1.7 MB) Additional infertility 80% (PDF, 1.7 MB) Additional infertility 95% (PDF, 1.7 MB)	English (PDF, 1.1 MB)

© California Physicians' Service DBA Blue Shield of California 1999-2024. All rights reserved. California Physicians’ Service DBA Blue Shield of California is an independent member of the Blue Shield Association. Health insurance products are offered by Blue Shield of California Life & Health Insurance Company. Health plans are offered by Blue Shield of California.

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Summary of Benefits 2022

HMO plans

PPO plans

EPO plans