Summary of Benefits 2023

The Summary of Benefits (SOB) documents will include the coverage information you are used to seeing but in a much-simplified format. The format makes it easier for members to read and understand their plan benefits. SOBs will be included in new business proposals and renewals, open-enrollment materials, as well as member welcome kits as part of the Evidence of Coverage (EOC).

See FAQs about the new Summary of Benefits.

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

Added Advantage Point of Service plans

Added Advantage POSSM plans Summary of Benefits Optional benefits Disclosures
Added Advantage POSSM 500-100/80/60 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 273 KB)
Not marketed Added Advantage POSSM plans Summary of Benefits Optional benefits Disclosures
Added Advantage POSSM  300-100/90/70 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)

HMO plans

Access+ HMO plans Summary of Benefits Optional benefits Disclosures
Access+ HMO® Zero Admit 10 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Access+ HMO® Zero Admit 15 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Access+ HMO® Zero Admit 20 English (PDF, 169 KB)
Spanish (PDF, 196 MB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 141 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Access+ HMO® Zero Admit 30 English (PDF, 169 KB)
Spanish (PDF, 196 MB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Access+ HMO® Per Admit 10-250 English (PDF, 169 KB)
Spanish (PDF, 197 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Access+ HMO® Per Admit 20-250 English (PDF, 169 KB)
Spanish (PDF, 197 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Access+ HMO® Per Admit 20-500 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Access+ HMO® Per Admit 25-750 English (PDF, 169 KB)
Spanish (PDF, 197 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Access+ HMO® Per Admit 40-1000 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Access+ HMO® Per Day 15-500 English (PDF, 169 KB)
Spanish (PDF, 197 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Access+ HMO® Per Day 20-250 English (PDF, 169 KB)
Spanish (PDF, 197 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Access+ HMO® Per Day 20-500 English (PDF, 169 KB)
Spanish (PDF, 197 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Access+ HMO® Per Day 25-750  English (PDF, 170 KB)
Spanish (PDF, 197 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Access+ HMO® Per Day 30-500 English (PDF, 169 KB)
Spanish (PDF, 197 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Access+ HMO® Facility Coinsurance
15-20%		 English (PDF, 169 KB)
Spanish (PDF, 197 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Access+ HMO® Facility Coinsurance
20-20%		 English (PDF, 169 KB)
Spanish (PDF, 197 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Access+ HMO® Facility Coinsurance
25-25%		 English (PDF, 169 KB)
Spanish (PDF, 197 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Access+ HMO® Facility Coinsurance 30-30% English (PDF, 169 KB)
Spanish (PDF, 197 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Access+ HMO® Facility Coinsurance
40-40%		 English (PDF, 169 KB)
Spanish (PDF, 197 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Access+ HMO® Zero Facility Deductible
30-20%		 English (PDF, 169 KB)
Spanish (PDF, 197 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Access+ HMO® Facility Deductible 15-10%/250 English (PDF, 172 KB)
Spanish (PDF, 202 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Access+ HMO® Facility Deductible 15-10%/500 English (PDF, 172 KB)
Spanish (PDF, 202 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Access+ HMO® Facility Deductible 15-10%/750 English (PDF, 172 KB)
Spanish (PDF, 202 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Access+ HMO® Facility Deductible
15-10%/1500		 English (PDF, 1 MB)
Spanish (PDF, 161 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Access+ HMO® Facility Deductible
20-25%/1500		 English (PDF, 172 KB)
Spanish (PDF, 202 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Access+ HMO® Facility Deductible
30-10%/1500		 English (PDF, 172 KB)
Spanish (PDF, 202 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Access+ HMO® Facility Deductible 30-30%/2000 English (PDF, 172 KB)
Spanish (PDF, 202 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Access+ HMO® Facility Deductible 40-40%/2000 English (PDF, 172 KB)
Spanish (PDF, 202 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Local Access+ HMO plans Summary of Benefits Optional benefits Disclosures
Local Access+ HMO® Zero Admit 10 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Local Access+ HMO® Zero Admit 20 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Local Access+ HMO® Zero Admit 30 English (PDF, 169 KB)
Spanish (PDF, 196 MB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Local Access+ HMO® Per Admit 10-250 English (PDF, 169 KB)
Spanish (PDF, 197 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Local Access+ HMO® Per Admit 20-250 English (PDF, 169 KB)
Spanish (PDF, 197 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Local Access+ HMO® Per Admit 20-500 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Local Access+ HMO® Per Admit 25-750 English (PDF, 169 KB)
Spanish (PDF, 197 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Local Access+ HMO® Per Admit 40-1000 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Local Access+ HMO® Per Day 20-250 English (PDF, 169 KB)
Spanish (PDF, 197 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Local Access+ HMO® Per Day 20-500 English (PDF, 169 KB)
Spanish (PDF, 197 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Local Access+ HMO® Per Day 30-500 English (PDF, 169 KB)
Spanish (PDF, 197 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Local Access+ HMO® Facility Coinsurance
20-20%		 English (PDF, 169 KB)
Spanish (PDF, 197 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Local Access+ HMO® Facility Coinsurance
25-25%		 English (PDF, 169 KB)
Spanish (PDF, 197 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Local Access+ HMO® Facility Coinsurance 30-30%/2000 English (PDF, 169 KB)
Spanish (PDF, 197 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Local Access+ HMO® Facility Coinsurance
40-40%/2000		 English (PDF, 169 KB)
Spanish (PDF, 197 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Trio HMO plans Summary of Benefits Optional benefits Disclosures
TriTrio HMO Zero Admit 10 English (PDF, 169 KB)
Spanish (PDF, 197 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Trio HMO Zero Admit 15 English (PDF, 172 KB)
Spanish (PDF, 202 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Trio HMO Zero Admit 20 English (PDF, 172 KB)
Spanish (PDF, 202 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Trio HMO Zero Admit 30 English (PDF, 172 KB)
Spanish (PDF, 202 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Trio HMO Zero Admit 10-250 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Trio HMO Zero Admit 20-250 English (PDF, 172 KB)
Spanish (PDF, 202 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Trio HMO Zero Admit 20-500 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Trio HMO Per Admit 25-750 English (PDF, 172 KB)
Spanish (PDF, 202 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Trio HMO Per Admit 40-1000 English (PDF, 172 KB)
Spanish (PDF, 202 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Trio HMO Per Day 15-500 English (PDF, 172 KB)
Spanish (PDF, 202 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Trio HMO Per Day 25-750 English (PDF, 172 KB)
Spanish (PDF, 202 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Trio HMO Per Day 20-250 English (PDF, 172 KB)
Spanish (PDF, 202 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Trio HMO Per Day 20-500 English (PDF, 169 KB)
Spanish (PDF, 197 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Trio HMO Per Day 30-500 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Trio HMO  Facility Coinsurance 15-20% English (PDF, 169 KB)
Spanish (PDF, 197 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Trio HMO Facility Coinsurance 20-20% English (PDF, 169 KB)
Spanish (PDF, 197 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Trio HMO Facility Coinsurance 25-25% English (PDF, 172 KB)
Spanish (PDF, 202 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Trio HMO Facility Coinsurance 30-30% English (PDF, 172 KB)
Spanish (PDF, 202 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Trio HMO Facility Coinsurance 40-40% English (PDF, 172 KB)
Spanish (PDF, 202 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Trio HMO Zero Facility Deductible 30-20% English (PDF, 172 KB)
Spanish (PDF, 202 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Trio HMO  Facility Deductible 15-10%/250 English (PDF, 172 KB)
Spanish (PDF, 202 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Trio HMO Facility Deductible 15-10%/500 English (PDF, 172 KB)
Spanish (PDF, 202 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Trio HMO Facility Deductible 15-10%/750 English (PDF, 172 KB)
Spanish (PDF, 202 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Trio HMO Facility Deductible 15-10%/1500 English (PDF, 172 KB)
Spanish (PDF, 202 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Trio HMO Facility Deductible 20-25%/1500 English (PDF, 172 KB)
Spanish (PDF, 202 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Trio HMO  Facility Deductible 30-10%/1500 English (PDF, 172 KB)
Spanish (PDF, 202 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Trio HMO Facility Deductible 30-30%/2000 English (PDF, 172 KB)
Spanish (PDF, 202 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Trio HMO  Facility Deductible 40-40%/2000 English (PDF, 172 KB)
Spanish (PDF, 202 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Not marketed HMO plans Summary of Benefits Optional benefits Disclosures
Access+ HMO® Facility Deductible 40-40%/5800 English (PDF, 173 KB)
Spanish (PDF, 202 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Access+ HMO® SaveNet Facility Coinsurance 15-20% English (PDF, 169 KB)
Spanish (PDF, 197 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Access+ HMO® SaveNet Facility Coinsurance 20-20% English (PDF, 169 KB)
Spanish (PDF, 197 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Access+ HMO® SaveNet Facility Coinsurance 25-25% English (PDF, 169 KB)
Spanish (PDF, 197 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Access+ HMO® SaveNet Facility Deductible 40-40% English (PDF, 169 KB)
Spanish (PDF, 197 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Access+ HMO® SaveNet Facility Deductible 15-10%/1500 English (PDF, 169 KB)
Spanish (PDF, 197 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Access+ HMO® SaveNet Facility Deductible 20-25%/1500 English (PDF, 169 KB)
Spanish (PDF, 197 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Access+ HMO® SaveNet Facility Deductible 30-30%/2000 English (PDF, 169 KB)
Spanish (PDF, 197 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Access+ HMO® SaveNet Facility Deductible 40-40%/2000 English (PDF, 169 KB)
Spanish (PDF, 197 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Access+ HMO® SaveNet Facility Deductible 40-40%/5800 English (PDF, 169 KB)
Spanish (PDF, 197 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Access+ HMO® SaveNet Per Admit 10-250 English (PDF, 169 KB)
Spanish (PDF, 197 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Access+ HMO® SaveNet Per Admit 20-500 English (PDF, 169 KB)
Spanish (PDF, 197 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Access+ HMO® SaveNet Per Admit 25-750 English (PDF, 169 KB)
Spanish (PDF, 197 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Access+ HMO® SaveNet Per Admit 40-1000 English (PDF, 169 KB)
Spanish (PDF, 197 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Access+ HMO® SaveNet Zero Admit 10 English (PDF, 169 KB)
Spanish (PDF, 197 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Access+ HMO® SaveNet Zero Admit 20 English (PDF, 169 KB)
Spanish (PDF, 197 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Access+ HMO® SaveNet Zero Admit 30 English (PDF, 169 KB)
Spanish (PDF, 197 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Local Access+ HMO® Facility Coinsurance 15-20% English (PDF, 169 KB)
Spanish (PDF, 197 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Local Access+ HMO® Facility Coinsurance 40-40% English (PDF, 169 KB)
Spanish (PDF, 197 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Local Access+ HMO® Facility Deductible 15-10%/1500 English (PDF, 169 KB)
Spanish (PDF, 197 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Local Access+ HMO® Facility Deductible 20-25%/1500 English (PDF, 169 KB)
Spanish (PDF, 197 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Local Access+ HMO® Facility Deductible 40-40%/5800 English (PDF, 169 KB)
Spanish (PDF, 197 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)
Trio HMO Facility Deductible 40-40%/5800 English (PDF, 169 KB)
Spanish (PDF, 197 KB)		 English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Chiropractic (PDF, 141 KB)
Chiropractic and acupuncture (PDF, 131 KB)
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (PDF, 245 KB)

PPO plans

Full  PPO plans Summary of Benefits Optional benefits Disclosures
Full PPO No Network Deductible 10 100/50 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (273 KB)
Full PPO No Network Deductible 20 100/50 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (273 KB)
Full PPO Combined Deductible 0-250 80/60 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (273 KB)
Full PPO Combined Deductible 0-250 90/70 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (273 KB)
Full PPO Combined Deductible 0-400 90/70 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (273 KB)
Full PPO Combined Deductible 10-250 90/70 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (273 KB)
Full PPO Combined Deductible 10-500 90/70 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (273 KB)
Full PPO Combined Deductible 15-250 90/70 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (273 KB)
Full PPO Combined Deductible 20-200 90/70 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (273 KB)
Full PPO Combined Deductible 20-250 80/60 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (273 KB)
Full PPO Combined Deductible 25-250 80/60 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (273 KB)
Full PPO Combined Deductible 25-250 90/60 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (273 KB)
Full PPO Combined Deductible 30-500 90/60 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (273 KB)
Full PPO Combined Deductible 30-750 80/60 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (273 KB)
Full PPO Combined Deductible 35-500 80/60 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (273 KB)
Full PPO Combined Deductible Value 10-1000 90/70 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (273 KB)
Full PPO Combined Deductible Value 15-1500 80/50 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (273 KB)
Full PPO Combined Deductible Value 20-2000 80/50 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (273 KB)
Full PPO Combined Deductible Value 25-2500 80/50 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (273 KB)
Full PPO Combined Deductible Value 30-3000 80/50 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (273 KB)
Full PPO Combined Deductible Value 40-4000 80/50 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (273 KB)
Full PPO Split Deductible 0-1750 80/60 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (273 KB)
Full PPO Split Deductible 0-500 80/60 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (273 KB)
Full PPO Split Deductible 10-250 90/70 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (273 KB)
Full PPO Split Deductible 15-500 90/60 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (273 KB)
Full PPO Split Deductible 20-500 80/60 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (273 KB)
Full PPO Split Deductible 25-750 80/60 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (273 KB)
Full PPO Split Deductible 35-1000 80/60 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (273 KB)
Full PPO Split Deductible 30-2000 70/50 English (PDF, 169 KB)
Spanish (PDF, 196 KB		 English
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (273 KB)
Full PPO Split Deductible 40-4000 70/50 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (273 KB)
Full PPO Savings Two-Tier plans Summary of Benefits Optional benefits Disclosures
Full PPO Savings Two-Tier Embedded Deductible 1500/3000/3000 90/70 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (245 KB)
Full PPO Savings Two-Tier Embedded Deductible 1500/3000/3000 90/60 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (245 KB)
Full PPO Savings Two-Tier Embedded Deductible 1500/3000/3000 100% English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (245 KB)
Full PPO Savings Two-Tier Embedded Deductible 1500/3000/3000 with $0 HDHP Preventive Drug Benefit English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (245 KB)
Full PPO Savings Two-Tier Embedded Deductible 1800/3000/3600 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (245 KB)
Full PPO Savings Two-Tier Embedded Deductible 2250/3000/4500 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (245 KB)
Full PPO Savings Two-Tier Embedded Deductible 2250/3000/4500 with $0 HDHP Preventive Drug Benefit English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (245 KB)
Full PPO Savings Two-Tier Embedded Deductible 1500/3000/3000 with Value Formulary English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 123 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)		 English (245 KB)
Full PPO Savings plans Summary of Benefits Optional benefits Disclosures
Full PPO Savings Embedded Deductible 3000/5200 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 127 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 128 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)		 English (256 KB)
Full PPO Savings Embedded Deductible 3000/6000 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 127 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 128 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)		 English (256 KB)
Full PPO Savings Embedded Deductible 3000 100% English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 127 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 128 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)		 English (256 KB)
Full PPO Savings Embedded Deductible 3500 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 127 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 128 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)		 English (256 KB)
Full PPO Savings Embedded Deductible 4000 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 127 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 128 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)		 English (256 KB)
Full PPO Savings Embedded Deductible 4400 100% English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 127 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 128 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)		 English (256 KB)
Full PPO Savings Embedded Deductible 5500 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 127 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 128 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)		 English (256 KB)
Full PPO Savings Embedded Deductible 5500 with Value Formulary English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 127 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 128 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)		 English (256 KB)
Full PPO Savings Embedded Deductible 6350 100% English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 127 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 128 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)		 English (256 KB)
Tandem PPO plans Summary of Benefits Optional benefits Disclosures
Tandem PPO No Network Deductible 10 100/50 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)		 English (254 KB)
Tandem PPO Combined Deductible 0-250 80/60 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)		 English (254 KB)
Tandem PPO Combined Deductible 0-250 90/70 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)		 English (254 KB)
Tandem PPO Combined Deductible 0-400 90/70 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)		 English (254 KB)
Tandem PPO Combined Deductible 10-250 90/70 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)		 English (254 KB)
Tandem PPO Combined Deductible 15-250 90/70 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)		 English (254 KB)
Tandem PPO Combined Deductible 20-250 80/60 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)		 English (254 KB)
Tandem PPO Split Deductible 0-1750 80/60 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)		 English (254 KB)
Tandem PPO Split Deductible 0-500 80/60 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)		 English (254 KB)
Tandem PPO Split Deductible 10-250 90/70 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)		 English (254 KB)
Tandem PPO Split Deductible 20-500 80/60 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)		 English (254 KB)
Tandem PPO Split Deductible 25-750 80/60 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)		 English (254 KB)
Tandem PPO Split Deductible 35-1000 80/60 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)		 English (254 KB)
Virtual Blue PPO plans Summary of Benefits Optional benefits Disclosures
Virtual BlueSM PPO Combined Deductible 20-250 80/60 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)		 English (218 KB)
Virtual BlueSM PPO Split Deductible 50-1000 70/50 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)		 English (218 KB)
Virtual BlueSM PPO Split Deductible 50-3000 60/50 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)		 English (218 KB)
Tandem PPO Savings plans Summary of Benefits Optional benefits Disclosures
Tandem PPO Savings Embedded Deductible 3000 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 127 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 128 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)		 English (255 KB)
Tandem PPO Savings Embedded Deductible 4425 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 127 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 128 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)		 English (255 KB)
Tandem PPO Savings Embedded Deductible 3000 100% English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 127 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 128 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)		 English (255 KB)
Tandem PPO Savings Embedded Deductible 5500 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 127 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 128 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)		 English (255 KB)
Tandem PPO Savings Embedded Deductible 6350 100% English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 127 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 128 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)		 English (255 KB)
Tandem PPO Savings Two-Tier Embedded Deductible plans Summary of Benefits Optional benefits Disclosures
Tandem PPO Savings Two-Tier Embedded Deductible 1500/3000/3000 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 127 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 128 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)		 English (256 KB)
Active Choice PPO plans Summary of Benefits Optional benefits Disclosures
Active Choice® Plus 300 20 80/60 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)		 English (274 KB)
Active Choice® Plus 300 80/60 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)		 English (274 KB)
Active Choice® Plus 1000 20 80/60 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)		 English (274 KB)
Active Choice® Plus 1000 80/60  English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)		 English (274 KB)
Active Choice® Classic 600 80/50 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)		 English (274 KB)
Active Choice® Classic 850 70/50 1000 Deductible English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)		 English (274 KB)
Active Choice® Classic 850 80/60 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)		 English (274 KB)
Not marketed PPO plans Summary of Benefits Optional benefits Disclosures
Full PPO Combined Deductible Value 50-4500 80/50 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)		 English (254 KB)
Shield Spectrum PPOSM 250-90/70 Standard English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)		 English (254 KB)
Tandem PPO Combined Deductible 20-200 90/70 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)		 English (254 KB)
Tandem PPO Combined Deductible 25-250 80/60 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)		 English (254 KB)
Tandem PPO Combined Deductible 25-250 90/60 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)		 English (254 KB)
Tandem PPO Combined Deductible Value 10-1000 90/70 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)		 English (254 KB)
Tandem PPO Split Deductible 30-1500 80/50 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)		 English (254 KB)
Tandem PPO Split Deductible 40-3000 70/50 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)		 English (254 KB)

EPO plans

Full  EPO plans Summary of Benefits Optional benefits Disclosures
Full EPO Zero Admit 20 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)		 English (254 KB)
Full EPO Zero Admit 30 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)		 English (254 KB)
Full EPO Per Admit 10-250 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)		 English (254 KB)
Full EPO Facility Coinsurance 20-20% English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)		 English (254 KB)
Full EPO 25-1500 80% English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)		 English (254 KB)
Full EPO 25-2500 80% English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)		 English (254 KB)
Full EPO 10-250 90% English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)		 English (254 KB)
Full EPO 20-500 80% English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)		 English (254 KB)
Tandem EPO plans Summary of Benefits Optional benefits Disclosures
Tandem EPO Zero Admit 20 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)		 English (253 KB)
Tandem EPO Zero Admit 30 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)		 English (253 KB)
Tandem EPO Per Admit 10-250 English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)		 English (253 KB)
Tandem EPO Facility Coinsurance 20-20% English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)		 English (253 KB)
Tandem EPO 25-1500 80% English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)		 English (253 KB)
Tandem EPO 25-2500 80% English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)		 English (253 KB)
Tandem EPO 10-250 90% English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)		 English (253 KB)
Tandem EPO 20-500 80% English (PDF, 169 KB)
Spanish (PDF, 196 KB)		 English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)		 English (253 KB)

© California Physicians' Service DBA Blue Shield of California 1999-2025. 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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