January 2022 Summary of Benefits

Off-Exchange Package
Mirror Package

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 0/0 OffEx	English Spanish	English	*Infertility* English Spanish
Platinum Tandem PPO 0/0 OffEx	English Spanish	English	Infertility English Spanish
Platinum Full PPO 0/10 OffEx	English Spanish	English	Infertility English Spanish
Platinum Tandem PPO 0/10 OffEx	English Spanish	English	Infertility English Spanish
Platinum Full PPO 250/10 OffEx	English Spanish	English	Infertility English Spanish
Platinum Tandem PPO 250/10 OffEx	English Spanish	English	Infertility English Spanish
Platinum Full PPO 250/15 OffEx	English Spanish	English	Infertility English Spanish
Platinum Tandem PPO 250/15 OffEx	English Spanish	English	Infertility English Spanish
Gold Full PPO 0/25 OffEx	English Spanish	English	Infertility English Spanish
Gold Tandem PPO 0/25 OffEx	English Spanish	English	Infertility English Spanish
Gold Full PPO 500/30 OffEx	English Spanish	English	Infertility English Spanish
Gold Tandem PPO 500/30 OffEx	English Spanish	English	*Infertility* English Spanish
Gold Full PPO 750/30 OffEx	English Spanish	English	*Infertility* English Spanish
Gold Tandem PPO 750/30 OffEx	English Spanish	English	*Infertility* English Spanish
Gold Full PPO 1000/35 OffEx	English Spanish	English	*Infertility* English Spanish
Gold Tandem PPO 1000/35 OffEx	English Spanish	English	*Infertility* English Spanish
Silver Full PPO 1800/45 OffEx	English Spanish	English	*Infertility* English Spanish
Silver Tandem PPO 1800/45 OffEx	English Spanish	English	*Infertility* English Spanish
Silver Full PPO 2225/50 OffEx	English Spanish	English	*Infertility* English Spanish
Silver Tandem PPO 2225/50 OffEx	English Spanish	English	*Infertility* English Spanish
Silver Full PPO 2400/55 OffEx	English Spanish	English	*Infertility* English Spanish
Silver Tandem PPO 2400/55 OffEx	English Spanish	English	*Infertility* English Spanish
Bronze Full PPO 5500/65 OffEx	English Spanish	English	*Infertility* English Spanish
Bronze Tandem PPO 5500/65 OffEx	English Spanish	English	*Infertility* English Spanish
Bronze Full PPO 6250/65 OffEx	English Spanish	English	*Infertility* English Spanish
Bronze Tandem PPO 6250/65 OffEx	English Spanish	English	*Infertility* English Spanish
Bronze Full PPO 6500/70 OffEx	English Spanish	English	*Infertility* English Spanish
Bronze Tandem PPO 6500/70 OffEx	English Spanish	English	*Infertility* English Spanish
Bronze Full PPO 7500/65 OffEx	English Spanish	English	*Infertility* English Spanish
Bronze Tandem PPO 7500/65 OffEx	English Spanish	English	*Infertility* English Spanish
Bronze Full PPO 6850/55 OffEx	English Spanish	English	*Infertility* English Spanish
Bronze Tandem PPO 6850/55 OffEx	English Spanish	English	*Infertility* English Spanish

Blue Shield Off-Exchange HSA HDHP Plans

Plans	Summary of Benefits	Disclosures	Optional Benefits
Gold Full PPO Savings 1750/15% HDHP PrevRx OffEx	English Spanish	English	*Infertility* English Spanish
Gold Tandem PPO Savings 1750/15% HDHP PrevRx OffEx	English Spanish	English	*Infertility* English Spanish
Silver Full PPO Savings 2100/25% OffEx	English Spanish	English	*Infertility* English Spanish
Silver Tandem PPO Savings 2100/25% OffEx	English Spanish	English	*Infertility* English Spanish
Silver Full PPO Savings 2600/35% HDHP PrevRx OffEx	English Spanish	English	*Infertility* English Spanish
Silver Tandem PPO Savings 2600/35% HDHP PrevRx OffEx	English Spanish	English	*Infertility* English Spanish
Bronze Full PPO Savings 5700/40% OffEx	English Spanish	English	*Infertility* English Spanish
Bronze Tandem PPO Savings 5700/40% OffEx	English Spanish	English	*Infertility* English Spanish
Bronze Full PPO Savings 7000 OffEx	English Spanish	English	*Infertility* English Spanish
Bronze Tandem PPO Savings 7000 OffEx	English Spanish	English	*Infertility* English Spanish

Blue Shield Off-Exchange HMO Plans

Plans	Summary of Benefits	Disclosures	Optional Benefits
Platinum Access+ HMO^® 0/20 OffEx	English Spanish	English	*Infertility* English Spanish
Platinum Local Access+ HMO^® 0/20 OffEx	English Spanish	English	*Infertility* English Spanish
Platinum Trio HMO 0/20 OffEx	English Spanish	English	*Infertility* English Spanish
Platinum Access+ HMO^® 0/25 OffEx	English Spanish	English	*Infertility* English Spanish
Platinum Local Access+ HMO^® 0/25 OffEx	English Spanish	English	*Infertility* English Spanish
Platinum Trio HMO 0/25 OffEx	English Spanish	English	*Infertility* English Spanish
Platinum Access+ HMO^® 0/30 OffEx	English Spanish	English	*Infertility* English Spanish
Platinum Local Access+ HMO^® 0/30 OffEx	English Spanish	English	*Infertility* English Spanish
Platinum Trio HMO 0/30 OffEx	English Spanish	English	*Infertility* English Spanish
Gold Access+ HMO^® 0/30 OffEx	English Spanish	English	*Infertility* English Spanish
Gold Local Access+ HMO^® 0/30 OffEx	English Spanish	English	*Infertility* English Spanish
Gold Trio HMO 0/30 OffEx	English Spanish	English	*Infertility* English Spanish
Gold Access+ HMO^® 500/35 OffEx	English Spanish	English	*Infertility* English Spanish
Gold Local Access+ HMO^® 500/35 OffEx	English Spanish	English	*Infertility* English Spanish
Gold Trio HMO 500/35 OffEx	English Spanish	English	*Infertility* English Spanish
Gold Access+ HMO^® 1000/35 OffEx	English Spanish	English	*Infertility* English Spanish
Gold Local Access+ HMO^® 1000/35 OffEx	English Spanish	English	*Infertility* English Spanish
Gold Trio HMO 1000/35 OffEx	English Spanish	English	*Infertility* English Spanish
Gold Access+ HMO ^® 1500/35 OffEx	English Spanish	English	*Infertility* English Spanish
Gold Local Access+ HMO ^® 1500/35 OffEx	English Spanish	English	*Infertility* English Spanish
Gold Trio HMO 1500/35 OffEx	English Spanish	English	*Infertility* English Spanish
Silver Access+ HMO ^® 2000/60 OffEx	English Spanish	English	*Infertility* English Spanish
Silver Access+ HMO ^® 2750/65 OffEx	English Spanish	English	*Infertility* English Spanish
Silver Local Access+ HMO ^® 2000/60 OffEx	English Spanish	English	*Infertility* English Spanish
Silver Local Access+ HMO ^® 2750/65 OffEx	English Spanish	English	*Infertility* English Spanish
Silver Trio HMO 2000/60 OffEx	English Spanish	English	*Infertility* English Spanish
Silver Trio HMO 2750/65 OffEx	English Spanish	English	*Infertility* English Spanish
Bronze Trio HMO 7000/70 OffEx	English Spanish	English	*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	Infertility English Spanish
Blue Shield Gold 80 PPO 350/25 + Child Dental	English Spanish	English	Infertility English Spanish
Blue Shield Silver 70 PPO 2250/50 + Child Dental	English Spanish	English	Infertility English Spanish
Blue Shield Bronze 60 PPO 6300/65 + Child Dental	English Spanish	English	Infertility English Spanish

Blue Shield Mirror HMO Plans

Plans	Summary of Benefits	Disclosures	Optional Benefits
Blue Shield Trio Platinum 90 HMO 0/20 + Child Dental	English Spanish	English	*Infertility* English Spanish
Blue Shield Trio Gold 80 HMO 250/35 + Child Dental	English Spanish	English	*Infertility* English Spanish
Blue Shield Trio Silver 70 HMO 2250/55 + Child Dental	English Spanish	English	*Infertility* English Spanish

Additional resources

Summary of benefits for previous years

Find a doctor