| Full PPO Plans | Summary of Benefits | Optional Benefits | Disclosures |
| Full PPO No Network Deductible 10 100/50 | English (PDF, 47KB) Spanish (PDF, 47KB) |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB) |
| Full PPO No Network Deductible 20 100/50 | English (PDF, 47KB) Spanish (PDF, 47KB) |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB) |
| Full PPO Combined Deductible 0-400 90/70 |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB) |
|
| Full PPO Combined Deductible 10-250 90/70 |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB) |
|
| Full PPO Combined Deductible 10-500 90/70 |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB) |
|
| Full PPO Combined Deductible 15-250 90/70 | English (PDF, 47KB) Spanish (PDF, 47KB) |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB) |
| Full PPO Combined Deductible 20-200 90/70 | English (PDF, 47KB) Spanish (PDF, 47KB) |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB) |
| Full PPO Combined Deductible 20-250 80/60 | English (PDF, 47KB) Spanish (PDF, 47KB) |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB) |
| Full PPO Combined Deductible 25-250 80/60 | English (PDF, 47KB) Spanish (PDF, 47KB) |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB) |
| Full PPO Combined Deductible 25-250 90/60 | English (PDF, 47KB) Spanish (PDF, 47KB) |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB) |
| Full PPO Combined Deductible 30-500 90/60 | English (PDF, 47KB) Spanish (PDF, 47KB) |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB) |
| Full PPO Combined Deductible 30-750 80/60 | English (PDF, 47KB) Spanish (PDF, 47KB) |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB) |
| Full PPO Combined Deductible 35-500 80/60 | English (PDF, 47KB) Spanish (PDF, 47KB) |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB) |
| Full PPO Combined Deductible Value 10-1000 90/70 | English (PDF, 47KB) Spanish (PDF, 47KB) |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB) |
| Full PPO Combined Deductible Value 15-1500 80/50 | English (PDF, 47KB) Spanish (PDF, 47KB) |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB) |
| Full PPO Combined Deductible Value 20-2000 80/50 | English (PDF, 47KB) Spanish (PDF, 47KB) |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB) |
| Full PPO Combined Deductible Value 25-2500 80/50 | English (PDF, 47KB) Spanish (PDF, 47KB) |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB) |
| Full PPO Combined Deductible Value 30-3000 80/50 | English (PDF, 47KB) Spanish (PDF, 47KB) |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB) |
| Full PPO Combined Deductible Value 40-4000 80/50 | English (PDF, 47KB) Spanish (PDF, 47KB) |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB) |
| Full PPO Combined Deductible Value 50-4500 80/50 | English (PDF, 47KB) Spanish (PDF, 47KB) |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB |
| Full PPO Split Deductible 0-1750 80/60 | English (PDF, 47KB) Spanish (PDF, 47KB) |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB |
| Full PPO Split Deductible 10-250 90/70 | English (PDF, 47KB) Spanish (PDF, 47KB) |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB |
| Full PPO Split Deductible 15-500 90/60 | English (PDF, 47KB) Spanish (PDF, 47KB) |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB) |
| Full PPO Split Deductible 20-500 80/60 | English ((PDF, 47KB) Spanish (PDF, 47KB) |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB) |
| Full PPO Split Deductible 25-750 80/60 | English (PDF, 47KB) Spanish (PDF, 47KB) |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB) |
| Full PPO Split Deductible 35-1000 80/60 | English (PDF, 47KB) Spanish (PDF, 47KB) |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB) |
| Full PPO Split Deductible 30-2000 70/50 | English (PDF, 47KB) Spanish (PDF, 47KB) |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB) |
| Full PPO Split Deductible 40-4000 70/50 | English (PDF, 47KB) Spanish (PDF, 47KB) |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB) |
| Full PPO Savings Two-Tier Plans | Summary of Benefits | Optional Benefits | Disclosures |
| Full PPO Savings Two-Tier Embedded Deductible 1400/2800/2800 |
English (PDF, 47KB) Spanish (PDF, 47KB) |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB) |
| Full PPO Savings Two-Tier Embedded Deductible 1500/2800/3000 |
English (PDF, 47KB) Spanish (PDF, 47KB) |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB) |
| Full PPO Savings Two-Tier Embedded Deductible 1500/2800/3000 100% |
English (PDF, 47KB) Spanish (PDF, 47KB) |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB) |
| Full PPO Savings Two-Tier Embedded Deductible 1500/2800/3000 with Value-Based Tier Drug Benefit |
English (PDF, 47KB) Spanish (PDF, 47KB) |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB) |
| Full PPO Savings Two-Tier Embedded Deductible 1800/2800/3600 |
English (PDF, 47KB) Spanish (PDF, 47KB) |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB) |
| Full PPO Savings Two-Tier Embedded Deductible 2250/2800/4500 |
English (PDF, 47KB) Spanish (PDF, 47KB) |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB) |
| Full PPO Savings Two-Tier Embedded Deductible 2250/2800/4500 with Value-Based Tier Drug Benefit |
English (PDF, 47KB) Spanish (PDF, 47KB) |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB) |
| Full PPO Savings Plans | Summary of Benefits | Optional Benefits | Disclosures |
| Full PPO Savings Embedded Deductible 2800 | English (PDF, 47KB) Spanish (PDF, 47KB) |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB) |
| Full PPO Savings Embedded Deductible 3000 | English (PDF, 47KB) Spanish (PDF, 47KB) |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB) |
| Full PPO Savings Embedded Deductible 3000 100% | English (PDF, 47KB) Spanish (PDF, 47KB) |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB) |
| Full PPO Savings Embedded Deductible 3500 | English (PDF, 47KB) Spanish (PDF, 47KB) |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB) |
| Full PPO Savings Embedded Deductible 4000 |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB) |
|
| Full PPO Savings Embedded Deductible 4400 100% |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB) |
|
| Full PPO Savings Embedded Deductible 5500 | English (PDF, 47KB) Spanish (PDF, 47KB) |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB) |
| Tandem PPO Plans | Summary of Benefits | Optional Benefits | Disclosures |
| Tandem PPO Combined Deductible 0-400 90/70 |
English (PDF, 47KB) Spanish (PDF, 47KB) |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB) |
| Tandem PPO Combined Deductible 10-250 90/70 |
English (PDF, 47KB) Spanish (PDF, 47KB) |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB) |
| Tandem PPO Combined Deductible 15-250 90/70 |
English (PDF, 47KB) Spanish (PDF, 47KB) |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB) |
| Tandem PPO Combined Deductible 20-200 90/70 |
English (PDF, 47KB) Spanish (PDF, 47KB) |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB) |
| Tandem PPO Combined Deductible 20-250 80/60 |
English (PDF, 47KB) Spanish (PDF, 47KB) |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB) |
| Tandem PPO Combined Deductible 25-250 80/60 |
English (PDF, 47KB) Spanish (PDF, 47KB) |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB) |
| Tandem PPO Combined Deductible 25-250 90/60 | English (PDF, 47KB) Spanish (PDF, 47KB) |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB) |
| Tandem PPO Combined Deductible Value 10-1000 90/70 |
English (PDF, 47KB) Spanish (PDF, 47KB) |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB) |
| Tandem PPO No Network Deductible 10 100/50 | English (PDF, 47KB) Spanish (PDF, 47KB) |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB) |
| Tandem PPO Split Deductible 0-1750 80/60 |
English (PDF, 47KB) Spanish (PDF, 47KB) |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB) |
| Tandem PPO Split Deductible 10-250 90/70 | English (PDF, 47KB) Spanish (PDF, 47KB) |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB)) |
| Tandem PPO Split Deductible 20-500 80/60 | English (PDF, 47KB) Spanish (PDF, 47KB) |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB) |
| Tandem PPO Split Deductible 25-750 80/60 | English (PDF, 47KB) Spanish (PDF, 47KB) |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB) |
| Tandem PPO Split Deductible 30-1500 80/50 | English (PDF, 47KB) Spanish (PDF, 47KB) |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB) |
| Tandem PPO Split Deductible 35-1000 80/60 | English (PDF, 47KB) Spanish (PDF, 47KB) |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB) |
| Tandem PPO Split Deductible 40-3000 70/50 | English (PDF, 47KB) Spanish (PDF, 47KB) |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB) |
| Tandem PPO Savings Embedded Deductible 3000 | English (PDF, 47KB) Spanish (PDF, 47KB) |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB) |
| Tandem PPO Savings Embedded Deductible 4425 | English (PDF, 47KB) Spanish (PDF, 47KB) |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB) |
| Active Choice PPO Plans | Summary of Benefits | Optional Benefits | Disclosures |
| Active Choice® 500 80/50 | English (PDF, 47KB) Spanish (PDF, 47KB) |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB) |
| Active Choice® 750 80/60 |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB) |
|
| Active Choice® 750 70/50 | English (PDF, 47KB) Spanish (PDF, 47KB) |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB) |
| Active Choice® 750 70/50 1000 Deductible | English (PDF, 47KB) Spanish (PDF, 47KB) |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB) |
| Active Choice® 500 80/50 1500 Deductible |
English (PDF, 47KB) Spanish (PDF, 47KB) |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB) |
| Not marketed PPO plans* | Summary of Benefits | Optional Benefits | Disclosures |
| Shield Spectrum PPO 250-90/70 Standard | English (PDF, 47KB) Spanish (PDF, 47KB) |
Hearing aid (PDF, 104KB) |
English (PDF, 25KB) Spanish (PDF, 25KB) |
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Blue Shield of California
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