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)

 

Contact Us

  • Producer Services (800) 559-5905

    Employer Services (800) 325-5166

  • Blue Shield of California

    PO Box 272540

    Chico, CA 95927-2540

© California Physicians’ Service DBA Blue Shield of California 1999-. All rights reserved. California Physicians’ Service DBA Blue Shield of California is an independent member of the Blue Shield Association.

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