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, 1 MB)
Spanish (PDF, 196 KB)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

English (PDF, 1.1 MB)
Full PPO Combined Deductible 40-6350 80/50 English (PDF, 1 MB)
Spanish (PDF, 196 KB)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

English (PDF, 1.1 MB)
Full PPO Split Deductible 50-5000 70/50 English (PDF, 1 MB)
Spanish (PDF, 196 KB)

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

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

English (PDF, 1.1 MB)
Full PPO Split Deductible 50-6350 70/50 English (PDF, 1 MB)
Spanish (PDF, 196 KB)

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

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

English (PDF, 1.1 MB)

 

 Full PPO Savings Two-Tier Plans Summary of Benefits Optional Benefits  Disclosures
Full PPO Savings Two-Tier
Embedded Deductible 1600/3200/3200 90/70
English (PDF, 1 MB)
Spanish (PDF, 196 KB)

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

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

English (PDF, 1.1 MB)
Full PPO Savings Two-Tier
Embedded Deductible 1600/3200/3200 90/60
English (PDF, 1 MB)
Spanish (PDF, 196 KB)

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

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

English (PDF, 1.1 MB)
Full PPO Savings Two-Tier
Embedded Deductible 1600/3200/3200 100%
English (PDF, 1 MB)
Spanish (PDF, 196 KB)

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

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

English (PDF, 1.1 MB)
Full PPO Savings Two-Tier
Embedded Deductible 1600/3200/3200
with $0 HDHP Preventive Drug Benefit
English (PDF, 1 MB)
Spanish (PDF, 196 KB)

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

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

English (PDF, 1.1 MB)
Full PPO Savings Two-Tier
Embedded Deductible 1800/3200/3600
English (PDF, 1 MB)
Spanish (PDF, 196 KB)

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

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

English (PDF, 1.1 MB)
Full PPO Savings Two-Tier
Embedded Deductible 2250/3200/4500
English (PDF, 1 MB)
Spanish (PDF, 196 KB)

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

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

English (PDF, 1.1 MB)
Full PPO Savings Two-Tier
Embedded Deductible 2250/3200/4500
with $0 HDHP Preventive Drug Benefit
English (PDF, 1 MB)
Spanish (PDF, 196 KB)

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

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

English (PDF, 1.1 MB)
Full PPO Savings Two-Tier
Embedded Deductible 1600/3200/3200
with Value Formulary
English (PDF, 1 MB)
Spanish (PDF, 196 KB)

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

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

English (PDF, 1.1 MB)
Tandem PPO Savings Two-Tier
Embedded Deductible 1600/3200/3200
English (PDF, 1 MB)
Spanish (PDF, 196 KB)

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

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

English (PDF, 1.1 MB)

 

 Full PPO Savings Plans Summary of Benefits Optional Benefits Disclosures
Full PPO Savings Embedded Deductible 3200/5200 English (PDF, 1 MB)
Spanish (PDF, 196 KB)

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

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

English (PDF, 1.1 MB)
Full PPO Savings Embedded Deductible 3200/6000 English (PDF, 1 MB)
Spanish (PDF, 196 KB)

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

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

English (PDF, 1.1MB)
Full PPO Savings Embedded Deductible 3200 100% English (PDF, 1 MB)
Spanish (PDF, 196 KB)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

English (PDF, 1.1 MB)
Tandem PPO Savings Plans Summary of Benefits Optional Benefits  Disclosures
Tandem PPO Savings Embedded Deductible 3200 English (PDF, 1 MB)
Spanish (PDF, 196 KB)

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

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

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

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

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

English (PDF, 1.1 MB)
Tandem PPO Savings Embedded Deductible 3200 100% English (PDF, 1 MB)
Spanish (PDF, 196 KB)

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

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

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

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

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

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

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

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

English (PDF, 1.1 MB)
Virtual Blue PPO Plans Summary of Benefits Optional Benefits  Disclosures
Virtual BlueSM PPO Combined Deductible 20-250 80/60 English (PDF, 223 KB)
Spanish (PDF, 262 KB)

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

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

English (PDF, 218 KB)
Virtual BlueSM PPO Split Deductible 50-1000 70/50 English (PDF, 223 KB)
Spanish (PDF, 262 KB)

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

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

English (PDF, 218 KB)
Virtual BlueSM PPO Split Deductible 50-3000 60/50 English (PDF, 223 KB)
Spanish (PDF, 262 KB)

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

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

English (PDF, 218 KB)
Virtual BlueSM PPO Combined Deductible 20-250 90/70 English (PDF, 223 KB)
Spanish (PDF, 265 KB)

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

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

English (PDF, 218 KB)
Virtual BlueSM PPO Combined Deductible 20-500 80/60 English (PDF, 223 KB)
Spanish (PDF, 263 KB)

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

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

English (PDF, 218 KB)
Virtual BlueSM PPO Split Deductible 20-250 90/70 English (PDF, 224 KB)
Spanish (PDF, 264 KB)

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

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

English (PDF, 218 KB)
Virtual BlueSM PPO Split Deductible 20-500 80/60 English (PDF, 224 KB)
Spanish (PDF, 264 KB)

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

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

English (PDF, 218 KB)
Virtual BlueSM PPO Split Deductible 20-750 80/60 English (PDF, 224 KB)
Spanish (PDF, 264 KB)

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

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

English (PDF, 218 KB)
Virtual BlueSM PPO Split Deductible 20-1000 80/60 English (PDF, 224 KB)
Spanish (PDF, 264 KB)

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

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

English (PDF, 218 KB)
Virtual BlueSM PPO Split Deductible 20-1500 80/60 English (PDF, 224 KB)
Spanish (PDF, 264 KB)

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

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

English (PDF, 218 KB)
Virtual BlueSM PPO Split Deductible 20-2000 70/50 English (PDF, 224 KB)
Spanish (PDF, 261 KB)

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

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

English (PDF, 218 KB)

 

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

Hearing aid (PDF, 1 MB)
Base infertility 50% (PDF, 727 KB)
Additional infertility 50% (PDF, 727 KB)
Additional infertility 80% (PDF, 728 KB)
Additional infertility 95% (PDF, 728 KB)

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

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

Hearing aid (PDF, 1 MB)
Base infertility 50% (PDF, 727 KB)
Additional infertility 50% (PDF, 727 KB)
Additional infertility 80% (PDF, 728 KB)
Additional infertility 95% (PDF, 728 KB)

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

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

Hearing aid (PDF, 1 MB)
Base infertility 50% (PDF, 727 KB)
Additional infertility 50% (PDF, 727 KB)
Additional infertility 80% (PDF, 728 KB)
Additional infertility 95% (PDF, 728 KB)

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

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

Hearing aid (PDF, 1 MB)
Base infertility 50% (PDF, 727 KB)
Additional infertility 50% (PDF, 727 KB)
Additional infertility 80% (PDF, 728 KB)
Additional infertility 95% (PDF, 728 KB)

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

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

Hearing aid (PDF, 1 MB)
Base infertility 50% (PDF, 727 KB)
Additional infertility 50% (PDF, 727 KB)
Additional infertility 80% (PDF, 728 KB)
Additional infertility 95% (PDF, 728 KB)

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

English (PDF, 1.1 MB)
Active Choice® Plus 300 80/60 2000 Deductible English (PDF, 882 KB)
Spanish (PDF, 919 KB)

Hearing aid (PDF, 1 MB)
Base infertility 50% (PDF, 727 KB)
Additional infertility 50% (PDF, 727 KB)
Additional infertility 80% (PDF, 728 KB)
Additional infertility 95% (PDF, 728 KB)

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

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

Hearing aid (PDF, 1 MB)
Base infertility 50% (PDF, 727 KB)
Additional infertility 50% (PDF, 727 KB)
Additional infertility 80% (PDF, 728 KB)
Additional infertility 95% (PDF, 728 KB)

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

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

Hearing aid (PDF, 1 MB)
Base infertility 50% (PDF, 727 KB)
Additional infertility 50% (PDF, 727 KB)
Additional infertility 80% (PDF, 728 KB)
Additional infertility 95% (PDF, 728 KB)

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

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

Hearing aid (PDF, 1 MB)
Base infertility 50% (PDF, 727 KB)
Additional infertility 50% (PDF, 727 KB)
Additional infertility 80% (PDF, 728 KB)
Additional infertility 95% (PDF, 728 KB)

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

English (PDF, 1.1 MB)
Active Choice® Classic 600 70/50 2000 Deductible English (PDF, 882 KB)
Spanish (PDF, 984 KB)

Hearing aid (PDF, 1 MB)
Base infertility 50% (PDF, 727 KB)
Additional infertility 50% (PDF, 727 KB)
Additional infertility 80% (PDF, 728 KB)
Additional infertility 95% (PDF, 728 KB)

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

English (PDF, 1.1 MB)

 

 Not Marketed PPO Plans Summary of Benefits Optional Benefits Disclosures
Full PPO Combined Deductible Value 50-4500 80/50 English (PDF, 1 MB)
Spanish (PDF, 196 KB)

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

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

English (PDF, 1.1 MB)
Shield Spectrum PPOSM 250-90/70 Standard English (PDF, 1.1 MB)
Spanish (PDF, 273 KB)

Hearing aid (PDF, 1 MB)
Base infertility 50% (PDF, 727 KB)
Additional infertility 50% (PDF, 727 KB)
Additional infertility 80% (PDF, 728 KB)
Additional infertility 95% (PDF, 728 KB)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

English (PDF, 1.1 MB)

 

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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.