January 2020 Summary of Benefits

Download summary of benefits and disclosures for Blue Shield Off-Exchange Package for Small Business.

PPO plans | HSA-compatible HDHP | HMO plans


Blue Shield Off-Exchange PPO Plans

Plans Summary of Benefits Disclosures Optional
Benefits
Platinum Full PPO 0/10 OffEx English
Spanish
English
Spanish
Infertility
English
Spanish
Platinum Full PPO 250/15 OffEx English
Spanish
English
Spanish
Infertility
English
Spanish
Gold Full PPO 0/20 OffEx English
Spanish
English
Spanish
Infertility
English
Spanish
Gold Full PPO 750/30 OffEx English
Spanish
English
Spanish
Infertility
English
Spanish
Silver Full PPO 2300/45 OffEx English
Spanish
English
Spanish
Infertility 
English
Spanish
Silver Full PPO 1800/55 OffEx English
Spanish
English
Spanish
Infertility 
English
Spanish
Bronze Full PPO 6850/65 OffEx English
Spanish
English
Spanish
Infertility 
English
Spanish
Gold Full PPO 1200/35 OffEx English
Spanish
English
Spanish
Infertility 
English
Spanish
Bronze Full PPO 5000/70 OffEx English
Spanish
English
Spanish
Infertility 
English
Spanish
Gold Full PPO 500/30 OffEx English
Spanish
English
Spanish
Infertility
English
Spanish
Platinum Tandem PPO 0/10 OffEx English
Spanish
English
Spanish
Infertility
English
Spanish
Platinum Tandem PPO 250/15 OffEx English
Spanish
English
Spanish
Infertility 
English
Spanish
Gold Tandem PPO 750/30 OffEx English
Spanish
English
Spanish
Infertility 
English
Spanish
Silver Tandem PPO 2300/45 OffEx English
Spanish
English
Spanish
Infertility 
English
Spanish
Silver Tandem PPO 1800/55 OffEx

English
Spanish

English
Spanish
Infertility 
English
Spanish
Bronze Tandem PPO 5000/70 OffEx

English
Spanish

English
Spanish
Infertility 
English
Spanish
Bronze Full PPO 6500/50 OffEx

English
Spanish

English
Spanish
Infertility 
English
Spanish
Bronze Tandem PPO 6500/50 OffEx

English
Spanish

English
Spanish
Infertility 
English
Spanish
Platinum Tandem PPO 0/0 OffEx

English
Spanish

English
Spanish
Infertility 
English
Spanish
Gold Tandem PPO 500/30 OffEx

English
Spanish

English
Spanish
Infertility 
English
Spanish
Gold Tandem PPO 1200/35 OffEx

English
Spanish

English
Spanish
Infertility 
English
Spanish
Gold Tandem PPO 0/20 OffEx

English
Spanish

English
Spanish
Infertility 
English
Spanish
Bronze Tandem PPO 6850/65 OffEx

English
Spanish

English
Spanish
Infertility 
English
Spanish
Platinum Full PPO 0/0 OffEx

English
Spanish

English
Spanish
Infertility 
English
Spanish


Blue Shield Off-Exchange HSA-HDHP Plans

Plans

Summary of Benefits Disclosures Optional
Benefits
Silver Full PPO Savings 2000/25% OffEx English
Spanish
English
Spanish
Infertility
English
Spanish
Bronze Full PPO Savings 5300/40% OffEx English
Spanish
English
Spanish
Infertility
English
Spanish
Bronze Full PPO Savings 6900 OffEx English
Spanish
English
Spanish
Infertility
English
Spanish
Silver Tandem PPO Savings 2000/25% OffEx English
Spanish
English
Spanish
Infertility
English
Spanish
Silver Tandem PPO Savings 2500/35% OffEx English
Spanish
English
Spanish
Infertility
English
Spanish
Silver Full PPO Savings 2500/35% OffEx English
Spanish
English
Spanish
Infertility
English
Spanish
Bronze Tandem PPO Savings 5300/40% OffEx English
Spanish
English
Spanish
Infertility
English
Spanish
Bronze Tandem PPO Savings 6900 OffEx English
Spanish
English
Spanish
Infertility
English
Spanish


Blue Shield Off-Exchange HMO Plans

Plans Summary of Benefits Disclosures Optional
Benefits
Platinum Local Access+ HMO® 0/25 OffEx English
Spanish
English
Spanish
Infertility
English
Spanish
Platinum Access+ HMO® 0/25 OffEx English
Spanish
English
Spanish
Infertility
English
Spanish
Gold Local Access+ HMO® 1500/35 OffEx English
Spanish
English
Spanish
Infertility
English
Spanish
Gold Access+ HMO® 1500/35 OffEx English
Spanish
English
Spanish
Infertility
English
Spanish
Silver Local Access+ HMO® 2350/65 OffEx English
Spanish
English
Spanish
Infertility
English
Spanish
Silver Access+ HMO® 2350/65 OffEx English
Spanish
English
Spanish
Infertility
English
Spanish
Platinum Trio HMO 0/25 OffEx English
Spanish
English
Spanish
Infertility
English
Spanish
Gold Trio HMO 1500/35 OffEx English
Spanish
English
Spanish
Infertility
English
Spanish
Silver Trio HMO 2350/65 OffEx English
Spanish

English
Spanish

Infertility
English
Spanish
Gold Access+ HMO® 500/35 OffEx English
Spanish
English
Spanish
Infertility
English
Spanish
Gold Local Access+ HMO® 500/35 OffEx

English
Spanish

English
Spanish
Infertility
English
Spanish
Gold Trio HMO 500/35 OffEx English
Spanish
English
Spanish
Infertility
English
Spanish
Platinum Access+ HMO® 0/20 OffEx English
Spanish
English
Spanish
Infertility
English
Spanish
Platinum Local Access+ HMO® 0/20 OffEx English
Spanish
English
Spanish
Infertility
English
Spanish
Platinum Trio HMO 0/20 OffEx English
Spanish
English
Spanish
Infertility
English
Spanish
Platinum Access+ HMO® 0/30 OffEx English
Spanish
English
Spanish
Infertility
English
Spanish
Platinum Local Access+ HMO® 0/30 OffEx English
Spanish
English
Spanish
Infertility
English
Spanish
Platinum Trio HMO 0/30 OffEx English
Spanish
English
Spanish
Infertility
English
Spanish
Gold Access+ HMO ® 0/30 OffEx English
Spanish
English
Spanish
Infertility
English
Spanish
Gold Local Access+ HMO ® 0/30 OffEx English
Spanish
English
Spanish
Infertility
English
Spanish
Gold Trio HMO 0/30 OffEx English
Spanish
English
Spanish
Infertility
English
Spanish
Gold Trio HMO 1000/35 OffEx English
Spanish
English
Spanish
Infertility
English
Spanish
Gold Local Access+ HMO ® 1000/35 OffEx English
Spanish
English
Spanish
Infertility
English
Spanish
Gold Access+ HMO ® 1000/35 OffEx English
Spanish
English
Spanish
Infertility
English
Spanish

Download summary of benefits and disclosures for Blue Shield Mirror Package for Small Business.

PPO plans | HMO plans


Blue Shield Mirror PPO Plans

Plans Summary of Benefits Disclosures Optional
Benefits
Blue Shield Platinum 90 PPO 0/15 + Child Dental English
Spanish
English
Spanish
Infertility
English
Spanish
Blue Shield Gold 80 PPO 250/25 + Child Dental English
Spanish

English
Spanish

Infertility
English
Spanish
Blue Shield Silver 70 PPO 2250/50 + Child Dental English
Spanish
English
Spanish
Infertility
English
Spanish
Blue Shield Bronze 60 PPO 6300/65 + Child Dental English
Spanish

English
Spanish

Infertility
English
Spanish


Blue Shield Mirror HMO Plans

Plans Summary of Benefits Disclosures Optional
Benefits
Blue Shield Trio Platinum 90 HMO 0/15 + Child Dental English
Spanish
English
Spanish
Infertility
English
Spanish
Blue Shield Trio Gold 80 HMO 250/25 + Child Dental English
Spanish
English
Spanish
Infertility
English
Spanish

Blue Shield Trio Silver 70 HMO 2250/50 + Child Dental

English
Spanish
English
Spanish
Infertility
English
Spanish