PPO Plans

PPO Plans

Prescription drug options

Full PPO Plans Summary of Benefits Optional Benefits  Disclosures
Full PPO No Network Deductible 10 100/50 English (PDF, 1MB)
Spanish (PDF, 196KB)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 English (PDF, 1.1MB)

 

 Full PPO Savings Two-Tier Plans Summary of Benefits Optional Benefits  Disclosures
Full PPO Savings Two-Tier
Embedded Deductible 1400/2800/2800		 English (PDF, 1MB)
Spanish (PDF, 196KB)

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

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

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

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

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

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

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

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

 English (PDF, 1.1MB)
Full PPO Savings Two-Tier
Embedded Deductible 1500/2800/3000
with $0 HDHP Preventive Drug Benefit		 English (PDF, 1MB)
Spanish (PDF, 196KB)

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

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

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

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

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

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

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

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

 English (PDF, 1.1MB)
Full PPO Savings Two-Tier
Embedded Deductible 2250/2800/4500
with $0 HDHP Preventive Drug Benefit		 English (PDF, 1MB)
Spanish (PDF, 196KB)

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

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

 English (PDF, 1.1MB)

 

 Full PPO Savings Plans Summary of Benefits Optional Benefits Disclosures
Full PPO Savings Embedded Deductible 2800 English (PDF, 1MB)
Spanish (PDF, 196KB)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 English (PDF, 1.1MB)
Tandem PPO Plans Summary of Benefits Optional Benefits  Disclosures
Tandem PPO No Network Deductible 10 100/50 English (PDF, 1MB)
Spanish (PDF, 196KB)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 English (PDF, 1.1MB)

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 English (PDF, 1.3MB)

 

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

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

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

 English (PDF, 1.1MB)
Active Choice® Plus 300 80/60 English (PDF, 882KB)
Spanish (PDF, 994KB)

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

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

 English (PDF, 1.1MB)
Active Choice® Plus 1000 20 80/60 English (PDF, 882KB)
Spanish (PDF, 994KB)

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

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

 English (PDF, 1.1MB)
Active Choice® Plus 1000 80/60 English (PDF, 882KB)
Spanish (PDF, 919KB)

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

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

 English (PDF, 1.1MB)
Active Choice® Classic 600 80/50 English (PDF, 882KB)
Spanish (PDF, 984KB)

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

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

 English (PDF, 1.1MB)
Active Choice® Classic 850 70/50 1000 Deductible English (PDF, 882KB)
Spanish (PDF, 984KB)

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

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

 English (PDF, 1.1MB)
Active Choice® Classic 850 80/60 English (PDF, 882KB)
Spanish (PDF, 984KB)

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

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

 English (PDF, 1.1MB)

 

 Not marketed PPO plans* Summary of Benefits Optional Benefits Disclosures
Shield Spectrum PPOSM 250-90/70 Standard English (PDF, 1.1MB)
Spanish (PDF, 273KB)

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

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

 English (PDF, 1.1MB)
 

 

Contact Us

  • Producer Services (800) 559-5905

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  • Blue Shield of California

    PO Box 272540

    Chico, CA 95927-2540

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Health insurance products are offered by Blue Shield of California Life & Health Insurance Company. Health plans are offered by Blue Shield of California.