Summary of Benefits 2024

Large Groups (101 and above)

 

The SOB documents will include the coverage information you are used to seeing but in a much-simplified format. The format makes it easier for members to read and understand their plan benefits. SOBs will be included in new business proposals and renewals, open-enrollment materials, as well as member welcome kits as part of the Evidence of Coverage (EOC).

When providing the Summary of Benefits to an applicant or Blue Shield member, you must also include a Notice of Language Assistance (PDF, 1.1 MB).

In addition, the Summary of Benefits and Coverage (SBC) Forms, provide your clients with an easy-to-understand overview of what our plans for groups of 101 and above cover. You can download SBC Forms and other resources for these plans:

  • PPO plans
  • HMO plans
  • HSA-compatible plans
  • Trio HMO plans
  • Point of service (POS) plans
  • Prescription drug options
Access+ HMO plans Summary of Benefits Optional benefits Disclosures
Access+ HMO® Zero Admit 10 English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Access+ HMO® Zero Admit 15 English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Access+ HMO® Zero Admit 20 English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Access+ HMO® Zero Admit 30 English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Access+ HMO® Per Admit 10-250 English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Access+ HMO® Per Admit 20-250 English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Access+ HMO® Per Admit 20-500 English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Access+ HMO® Per Admit 25-750 English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Access+ HMO® Per Admit 40-1000 English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Access+ HMO® Per Day 15-500 English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Access+ HMO® Per Day 20-250 English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Access+ HMO® Per Day 20-500 English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Access+ HMO® Per Day 25-750  English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Access+ HMO® Per Day 30-500 English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Access+ HMO® Facility Coinsurance
15-20%
English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Access+ HMO® Facility Coinsurance
20-20%
English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Access+ HMO® Facility Coinsurance
25-25%
English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Access+ HMO® Facility Coinsurance 30-30% English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Access+ HMO® Facility Coinsurance
40-40%
English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Access+ HMO® Zero Facility Deductible
30-20%
English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Access+ HMO® Facility Deductible 15-10%/250 English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Access+ HMO® Facility Deductible 15-10%/500 English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Access+ HMO® Facility Deductible 15-10%/750 English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Access+ HMO® Facility Deductible
15-10%/1500
English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Access+ HMO® Facility Deductible
20-25%/1500
English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Access+ HMO® Facility Deductible
30-10%/1500
English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Access+ HMO® Facility Deductible 30-30%/2000 English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Access+ HMO® Facility Deductible 40-40%/2000 English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Local Access+ HMO plans Summary of Benefits Optional benefits Disclosures
Local Access+ HMO® Zero Admit 10 English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Local Access+ HMO® Zero Admit 20 English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Local Access+ HMO® Zero Admit 30 English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Local Access+ HMO® Per Admit 10-250 English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Local Access+ HMO® Per Admit 20-250 English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Local Access+ HMO® Per Admit 20-500 English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Local Access+ HMO® Per Admit 25-750 English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Local Access+ HMO® Per Admit 40-1000 English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Local Access+ HMO® Per Day 20-250 English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Local Access+ HMO® Per Day 20-500 English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Local Access+ HMO® Per Day 30-500 English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Local Access+ HMO® Facility Coinsurance 20-20% English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Local Access+ HMO® Facility Coinsurance 25-25% English PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Local Access+ HMO® Facility Deductible 30-30%/2000 English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Local Access+ HMO® Facility Deductible 40-40%/2000 English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Trio HMO plans Summary of Benefits Optional benefits Disclosures
Trio HMO Zero Admit 10 English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Trio HMO Zero Admit 15 English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Trio HMO Zero Admit 20 English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Trio HMO Zero Admit 30 English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Trio HMO Per Admit 10-250 English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Trio HMO Per Admit 20-250 English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Trio HMO Per Admit 20-500 English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Trio HMO Per Admit 25-750 English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Trio HMO Per Admit 40-1000 English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Trio HMO Per Day 15-500 English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Trio HMO Per Day 25-750 English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Trio HMO Per Day 20-250 English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Trio HMO Per Day 20-500 English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Trio HMO Per Day 30-500 English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Trio HMO Facility Coinsurance 15-20% English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Trio HMO Facility Coinsurance 20-20% English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Trio HMO Facility Coinsurance 25-25% English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Trio HMO Facility Coinsurance 30-30% English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Trio HMO Facility Coinsurance 40-40% English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Trio HMO Zero Facility Deductible 30-20% English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Trio HMO Facility Deductible 15-10%/250 English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Trio HMO Facility Deductible 15-10%/500 English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Trio HMO Facility Deductible 15-10%/750 English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Trio HMO Facility Deductible 15-10%/1500 English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Trio HMO Facility Deductible 20-25%/1500 English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Trio HMO Facility Deductible 30-10%/1500 English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Trio HMO Facility Deductible 30-30%/2000 English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Trio HMO Facility Deductible 40-40%/2000 English (PDF, 1 MB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 992 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture (PDF, 1.7 MB)
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 (1.1 MB)
Not marketed HMO plans Summary of Benefits Optional benefits Disclosures
Access+ HMO® Facility
Deductible 40-40%/5800
English (PDF, 173 KB)
Spanish (PDF, 202 KB)
English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 128 KB)

Spanish
Chiropractic (PDF, 420 KB)
Chiropractic and acupuncture (PDF, 426 KB)
Hearing aid (PDF, 409 KB)
Base infertility 50% (PDF, 427 KB)
Additional infertility 50% (PDF, 422 KB)
Additional infertility 80% (PDF, 422 KB)
Additional infertility 95% (PDF, 422 KB)
English (245 KB)
Access+ HMO® SaveNet
Facility Coinsurance 15-20%
English (PDF, 173 KB)
Spanish (PDF, 197 KB)
English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 128 KB)

Spanish
Chiropractic (PDF, 420 KB)
Chiropractic and acupuncture (PDF, 426 KB)
Hearing aid (PDF, 409 KB)
Base infertility 50% (PDF, 427 KB)
Additional infertility 50% (PDF, 422 KB)
Additional infertility 80% (PDF, 422 KB)
Additional infertility 95% (PDF, 422 KB)
English (245 KB)
Access+ HMO® SaveNet
Facility Coinsurance 20-20%
English (PDF, 169 KB)
Spanish (PDF, 197 KB)
English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 128 KB)

Spanish
Chiropractic (PDF, 420 KB)
Chiropractic and acupuncture (PDF, 426 KB)
Hearing aid (PDF, 409 KB)
Base infertility 50% (PDF, 427 KB)
Additional infertility 50% (PDF, 422 KB)
Additional infertility 80% (PDF, 422 KB)
Additional infertility 95% (PDF, 422 KB)
English (245 KB)
Access+ HMO® SaveNet
Facility Coinsurance 25-25%
English (PDF, 169 KB)
Spanish (PDF, 197 KB)
English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 128 KB)

Spanish
Chiropractic (PDF, 420 KB)
Chiropractic and acupuncture (PDF, 426 KB)
Hearing aid (PDF, 409 KB)
Base infertility 50% (PDF, 427 KB)
Additional infertility 50% (PDF, 422 KB)
Additional infertility 80% (PDF, 422 KB)
Additional infertility 95% (PDF, 422 KB)
English (245 KB)
Access+ HMO® SaveNet
Facility Coinsurance 40-40%
English (PDF, 169 KB)
Spanish (PDF, 197 KB)
English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 128 KB)

Spanish
Chiropractic (PDF, 420 KB)
Chiropractic and acupuncture (PDF, 426 KB)
Hearing aid (PDF, 409 KB)
Base infertility 50% (PDF, 427 KB)
Additional infertility 50% (PDF, 422 KB)
Additional infertility 80% (PDF, 422 KB)
Additional infertility 95% (PDF, 422 KB)
English (245 KB)
Access+ HMO® SaveNet 
Facility Deductible
15-10%/1500
English (PDF, 169 KB)
Spanish (PDF, 197 KB)
English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 128 KB)

Spanish
Chiropractic (PDF, 420 KB)
Chiropractic and acupuncture (PDF, 426 KB)
Hearing aid (PDF, 409 KB)
Base infertility 50% (PDF, 427 KB)
Additional infertility 50% (PDF, 422 KB)
Additional infertility 80% (PDF, 422 KB)
Additional infertility 95% (PDF, 422 KB)
English (245 KB)
Access+ HMO® SaveNet
Facility Deductible
20-25%/1500
English (PDF, 169 KB)
Spanish (PDF, 197 KB)
English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 128 KB)

Spanish
Chiropractic (PDF, 420 KB)
Chiropractic and acupuncture (PDF, 426 KB)
Hearing aid (PDF, 409 KB)
Base infertility 50% (PDF, 427 KB)
Additional infertility 50% (PDF, 422 KB)
Additional infertility 80% (PDF, 422 KB)
Additional infertility 95% (PDF, 422 KB)
English (245 KB)
Access+ HMO® SaveNet
Facility Deductible
30-30%/2000
English (PDF, 169 KB)
Spanish (PDF, 197 KB)
English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 128 KB)

Spanish
Chiropractic (PDF, 420 KB)
Chiropractic and acupuncture (PDF, 426 KB)
Hearing aid (PDF, 409 KB)
Base infertility 50% (PDF, 427 KB)
Additional infertility 50% (PDF, 422 KB)
Additional infertility 80% (PDF, 422 KB)
Additional infertility 95% (PDF, 422 KB)
English (245 KB)
Access+ HMO® SaveNet
Facility Deductible
40-40%/2000
English (PDF, 169 KB)
Spanish (PDF, 197 KB)
English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 128 KB)

Spanish
Chiropractic (PDF, 420 KB)
Chiropractic and acupuncture (PDF, 426 KB)
Hearing aid (PDF, 409 KB)
Base infertility 50% (PDF, 427 KB)
Additional infertility 50% (PDF, 422 KB)
Additional infertility 80% (PDF, 422 KB)
Additional infertility 95% (PDF, 422 KB)
English (245 KB)
Access+ HMO® SaveNet
Facility Deductible
40-40%/5800
English (PDF, 169 KB)
Spanish (PDF, 197 KB)
English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 128 KB)

Spanish
Chiropractic (PDF, 420 KB)
Chiropractic and acupuncture (PDF, 426 KB)
Hearing aid (PDF, 409 KB)
Base infertility 50% (PDF, 427 KB)
Additional infertility 50% (PDF, 422 KB)
Additional infertility 80% (PDF, 422 KB)
Additional infertility 95% (PDF, 422 KB)
English (245 KB)
Access+ HMO® SaveNet
Per Admit 10-250
English (PDF, 169 KB)
Spanish (PDF, 197 KB)
English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 128 KB)

Spanish
Chiropractic (PDF, 420 KB)
Chiropractic and acupuncture (PDF, 426 KB)
Hearing aid (PDF, 409 KB)
Base infertility 50% (PDF, 427 KB)
Additional infertility 50% (PDF, 422 KB)
Additional infertility 80% (PDF, 422 KB)
Additional infertility 95% (PDF, 422 KB)
English (245 KB)
Access+ HMO® SaveNet
Per Admit 20-500
English (PDF, 169 KB)
Spanish (PDF, 197 KB)
English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 128 KB)

Spanish
Chiropractic (PDF, 420 KB)
Chiropractic and acupuncture (PDF, 426 KB)
Hearing aid (PDF, 409 KB)
Base infertility 50% (PDF, 427 KB)
Additional infertility 50% (PDF, 422 KB)
Additional infertility 80% (PDF, 422 KB)
Additional infertility 95% (PDF, 422 KB)
English (245 KB)
Access+ HMO® SaveNet
Per Admit 25-750
English (PDF, 169 KB)
Spanish (PDF, 197 KB)
English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 128 KB)

Spanish
Chiropractic (PDF, 420 KB)
Chiropractic and acupuncture (PDF, 426 KB)
Hearing aid (PDF, 409 KB)
Base infertility 50% (PDF, 427 KB)
Additional infertility 50% (PDF, 422 KB)
Additional infertility 80% (PDF, 422 KB)
Additional infertility 95% (PDF, 422 KB)
English (245 KB)
Access+ HMO® SaveNet
Per Admit 40-1000
English (PDF, 169 KB)
Spanish (PDF, 197 KB)
English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 128 KB)

Spanish
Chiropractic (PDF, 420 KB)
Chiropractic and acupuncture (PDF, 426 KB)
Hearing aid (PDF, 409 KB)
Base infertility 50% (PDF, 427 KB)
Additional infertility 50% (PDF, 422 KB)
Additional infertility 80% (PDF, 422 KB)
Additional infertility 95% (PDF, 422 KB)
English (245 KB)
Access+ HMO® SaveNet
Zero Admit 10
English (PDF, 169 KB)
Spanish (PDF, 197 KB)
English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 128 KB)

Spanish
Chiropractic (PDF, 420 KB)
Chiropractic and acupuncture (PDF, 426 KB)
Hearing aid (PDF, 409 KB)
Base infertility 50% (PDF, 427 KB)
Additional infertility 50% (PDF, 422 KB)
Additional infertility 80% (PDF, 422 KB)
Additional infertility 95% (PDF, 422 KB)
English (245 KB)
Access+ HMO® SaveNet
Zero Admit 20
English (PDF, 169 KB)
Spanish (PDF, 197 KB)
English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 128 KB)

Spanish
Chiropractic (PDF, 420 KB)
Chiropractic and acupuncture (PDF, 426 KB)
Hearing aid (PDF, 409 KB)
Base infertility 50% (PDF, 427 KB)
Additional infertility 50% (PDF, 422 KB)
Additional infertility 80% (PDF, 422 KB)
Additional infertility 95% (PDF, 422 KB)
English (245 KB)
Access+ HMO® SaveNet
Zero Admit 30
English (PDF, 169 KB)
Spanish (PDF, 197 KB)
English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 128 KB)

Spanish
Chiropractic (PDF, 420 KB)
Chiropractic and acupuncture (PDF, 426 KB)
Hearing aid (PDF, 409 KB)
Base infertility 50% (PDF, 427 KB)
Additional infertility 50% (PDF, 422 KB)
Additional infertility 80% (PDF, 422 KB)
Additional infertility 95% (PDF, 422 KB)
English (245 KB)
Local Access+ HMO® Facility Coinsurance 15-20% English (PDF, 169 KB)
Spanish (PDF, 197 KB)
English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 128 KB)

Spanish
Chiropractic (PDF, 420 KB)
Chiropractic and acupuncture (PDF, 426 KB)
Hearing aid (PDF, 409 KB)
Base infertility 50% (PDF, 427 KB)
Additional infertility 50% (PDF, 422 KB)
Additional infertility 80% (PDF, 422 KB)
Additional infertility 95% (PDF, 422 KB)
English (245 KB)
Local Access+ HMO® Facility Coinsurance 40-40% English (PDF, 169 KB)
Spanish (PDF, 197 KB)
English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 128 KB)

Spanish
Chiropractic (PDF, 420 KB)
Chiropractic and acupuncture (PDF, 426 KB)
Hearing aid (PDF, 409 KB)
Base infertility 50% (PDF, 427 KB)
Additional infertility 50% (PDF, 422 KB)
Additional infertility 80% (PDF, 422 KB)
Additional infertility 95% (PDF, 422 KB)
English (245 KB)
Local Access+ HMO® Facility Deductible 15-10%/1500 English (PDF, 169 KB)
Spanish (PDF, 197 KB)
English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 128 KB)

Spanish
Chiropractic (PDF, 420 KB)
Chiropractic and acupuncture (PDF, 426 KB)
Hearing aid (PDF, 409 KB)
Base infertility 50% (PDF, 427 KB)
Additional infertility 50% (PDF, 422 KB)
Additional infertility 80% (PDF, 422 KB)
Additional infertility 95% (PDF, 422 KB)
English (245 KB)
Local Access+ HMO® Facility Deductible 20-25%/1500 English (PDF, 169 KB)
Spanish (PDF, 197 KB)
English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 128 KB)

Spanish
Chiropractic (PDF, 420 KB)
Chiropractic and acupuncture (PDF, 426 KB)
Hearing aid (PDF, 409 KB)
Base infertility 50% (PDF, 427 KB)
Additional infertility 50% (PDF, 422 KB)
Additional infertility 80% (PDF, 422 KB)
Additional infertility 95% (PDF, 422 KB)
English (245 KB)
Local Access+ HMO® Facility Deductible 40-40%/5800 English (PDF, 169 KB)
Spanish (PDF, 197 KB)
English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 128 KB)

Spanish
Chiropractic (PDF, 420 KB)
Chiropractic and acupuncture (PDF, 426 KB)
Hearing aid (PDF, 409 KB)
Base infertility 50% (PDF, 427 KB)
Additional infertility 50% (PDF, 422 KB)
Additional infertility 80% (PDF, 422 KB)
Additional infertility 95% (PDF, 422 KB)
English (245 KB)
Trio HMO Facility Deductible 40-40%/5800 English (PDF, 169 KB)
Spanish (PDF, 161 KB)
English
Chiropractic (PDF, 128 KB)
Chiropractic and acupuncture (PDF, 994 KB)
Hearing aid (PDF, 987 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 128 KB)

Spanish
Chiropractic (PDF, 420 KB)
Chiropractic and acupuncture (PDF, 426 KB)
Hearing aid (PDF, 409 KB)
Base infertility 50% (PDF, 427 KB)
Additional infertility 50% (PDF, 422 KB)
Additional infertility 80% (PDF, 422 KB)
Additional infertility 95% (PDF, 422 KB)
English (245 KB)
Full PPO plans Summary of Benefits Optional benefits Disclosures
Full PPO Combined Deductible Value 10-1000 90/70 English (PDF, 1 MB)
Spanish (PDF, 196 KB)
English
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 15-1500 80/50 English (PDF, 1 MB)
Spanish (PDF, 196 KB)
English
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)
English
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)
English
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)
English
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)
English
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)
English
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)
English
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)
English
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)
English
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, 1 MB)
Spanish (PDF, 196 KB)
English
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)
English
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)
English
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)
English
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)
English
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)
English
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)
English
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)
English
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)
English
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 100%
English (PDF, 1 MB)
Spanish (PDF, 196 KB)
English
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)
English
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)
English
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)
English
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
with $0 HDHP Preventive Drug Benefit
English (PDF, 1 MB)
Spanish (PDF, 196 KB)
English
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)
English
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)
English
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, 467 KB)
Spanish (PDF, 516 KB)
English
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, 255 KB)
Full PPO Savings Embedded Deductible 3200/6000 English (PDF, 467 KB)
Spanish (PDF, 516 KB)
English
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, 255 KB)
Full PPO Savings Embedded Deductible 3200 100% English (PDF, 467 KB)
Spanish (PDF, 516 KB)
English
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, 255 KB)
Full PPO Savings Embedded Deductible 3500 English (PDF, 467 KB)
Spanish (PDF, 516 KB)
English
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, 255 KB)
Full PPO Savings Embedded Deductible 4000 English (PDF, 467 KB)
Spanish (PDF, 516 KB)
English
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, 255 KB)
Full PPO Savings Embedded Deductible 4400 100% English (PDF, 467 KB)
Spanish (PDF, 516 KB)
English
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, 255 KB)
Full PPO Savings Embedded Deductible 5500 English (PDF, 467 KB)
Spanish (PDF, 516 KB)
English
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, 255 KB)
Full PPO Savings Embedded Deductible 5500 with Value Formulary English (PDF, 467 KB)
Spanish (PDF, 516 KB)
English
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, 255 KB)
Full PPO Savings Embedded Deductible 6350 100% English (PDF, 467 KB)
Spanish (PDF, 516 KB)
English
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, 255 KB)
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)
English
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)
English
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)
English
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)
English
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)
English
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)
English
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
20-250 80/60
English (PDF, 1 MB)
Spanish (PDF, 196 KB)
English
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)
English
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)
English
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 10-250 90/70 English (PDF, 1 MB)
Spanish (PDF, 196 KB)
English
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)
English
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)
English
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)
English
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)
English
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)
English
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)
English
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)
English
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)
English
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)
Active Choice PPO plans Summary of Benefits Optional benefits  Disclosures
Active Choice® Plus 300 20 80/60 English (PDF, 1 MB)
Spanish (PDF, 196 KB)
English
Hearing aid (PDF, 347 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 128 KB)

Spanish
Hearing aid (PDF, 409 KB)
Base infertility 50% (PDF, 427 KB)
Additional infertility 50% (PDF, 422 KB)
Additional infertility 80% (PDF, 421 KB)
Additional infertility 95% (PDF, 421 KB)
English (PDF, 273 KB)
Active Choice® Plus 300 80/60 English (PDF, 1 MB)
Spanish (PDF, 196 KB)
English
Hearing aid (PDF, 347 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 128 KB)

Spanish
Hearing aid (PDF, 409 KB)
Base infertility 50% (PDF, 427 KB)
Additional infertility 50% (PDF, 422 KB)
Additional infertility 80% (PDF, 421 KB)
Additional infertility 95% (PDF, 421 KB)
English (PDF, 273 KB)
Active Choice® Plus 1000 20 80/60 English (PDF, 1 MB)
Spanish (PDF, 196 KB)
English
Hearing aid (PDF, 347 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 128 KB)

Spanish
Hearing aid (PDF, 409 KB)
Base infertility 50% (PDF, 427 KB)
Additional infertility 50% (PDF, 422 KB)
Additional infertility 80% (PDF, 421 KB)
Additional infertility 95% (PDF, 421 KB)
English (PDF, 273 KB)
Active Choice® Plus 1000 80/60 English (PDF, 1 MB)
Spanish (PDF, 196 KB)
English
Hearing aid (PDF, 347 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 128 KB)

Spanish
Hearing aid (PDF, 409 KB)
Base infertility 50% (PDF, 427 KB)
Additional infertility 50% (PDF, 422 KB)
Additional infertility 80% (PDF, 421 KB)
Additional infertility 95% (PDF, 421 KB)
English (PDF, 273 KB)
Active Choice® Plus 1000 80/60 1000 Deductible English (PDF, 1 MB)
Spanish (PDF, 196 KB)
English
Hearing aid (PDF, 347 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 128 KB)

Spanish
Hearing aid (PDF, 409 KB)
Base infertility 50% (PDF, 427 KB)
Additional infertility 50% (PDF, 422 KB)
Additional infertility 80% (PDF, 421 KB)
Additional infertility 95% (PDF, 421 KB)
English (PDF, 273 KB)
Active Choice® Plus 300 80/60 2000 Deductible English (PDF, 1 MB)
Spanish (PDF, 196 KB)
English
Hearing aid (PDF, 347 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 128 KB)

Spanish
Hearing aid (PDF, 409 KB)
Base infertility 50% (PDF, 427 KB)
Additional infertility 50% (PDF, 422 KB)
Additional infertility 80% (PDF, 421 KB)
Additional infertility 95% (PDF, 421 KB)
English (PDF, 273 KB)
Active Choice® Classic 600 80/50 English (PDF, 1 MB)
Spanish (PDF, 196 KB)
English
Hearing aid (PDF, 347 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 128 KB)

Spanish
Hearing aid (PDF, 409 KB)
Base infertility 50% (PDF, 427 KB)
Additional infertility 50% (PDF, 422 KB)
Additional infertility 80% (PDF, 421 KB)
Additional infertility 95% (PDF, 421 KB)
English (PDF, 273 KB)
Active Choice® Classic 850 70/50 1000 Deductible English (PDF, 1 MB)
Spanish (PDF, 196 KB)
English
Hearing aid (PDF, 347 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 128 KB)

Spanish
Hearing aid (PDF, 409 KB)
Base infertility 50% (PDF, 427 KB)
Additional infertility 50% (PDF, 422 KB)
Additional infertility 80% (PDF, 421 KB)
Additional infertility 95% (PDF, 421 KB)
English (PDF, 273 KB)
Active Choice® Classic 850 80/60 English (PDF, 1 MB)
Spanish (PDF, 196 KB)
English
Hearing aid (PDF, 347 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 128 KB)

Spanish
Hearing aid (PDF, 409 KB)
Base infertility 50% (PDF, 427 KB)
Additional infertility 50% (PDF, 422 KB)
Additional infertility 80% (PDF, 421 KB)
Additional infertility 95% (PDF, 421 KB)
English (PDF, 273 KB)
Active Choice® Classic 600 70/50 2000 Deductible English (PDF, 1 MB)
Spanish (PDF, 196 KB)
English
Hearing aid (PDF, 347 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 128 KB)

Spanish
Hearing aid (PDF, 409 KB)
Base infertility 50% (PDF, 427 KB)
Additional infertility 50% (PDF, 422 KB)
Additional infertility 80% (PDF, 421 KB)
Additional infertility 95% (PDF, 421 KB)
English (PDF, 273 KB)
Not Marketed PPO plans Summary of Benefits Optional benefits  Disclosures
Full PPO Combined Deductible Value 50-4500 80/50 English (PDF, 169 KB)
Spanish (PDF, 196 KB)
English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)
English (254 KB)
Shield Spectrum PPOSM 250-90/70 Standard English (PDF, 169 KB)
Spanish (PDF, 196 KB)
English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)
English (254 KB)
Tandem PPO Combined Deductible 20-200 90/70 English (PDF, 169 KB)
Spanish (PDF, 196 KB)
English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)
English (254 KB)
Tandem PPO Combined Deductible 25-250 80/60 English (PDF, 169 KB)
Spanish (PDF, 196 KB)
English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)
English (254 KB)
Tandem PPO Combined Deductible 25-250 90/60 English (PDF, 169 KB)
Spanish (PDF, 196 KB)
English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)
English (254 KB)
Tandem PPO Combined Deductible Value 10-1000 90/70 English (PDF, 169 KB)
Spanish (PDF, 196 KB)
English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)
English (254 KB)
Tandem PPO Split Deductible 30-1500 80/50 English (PDF, 169 KB)
Spanish (PDF, 196 KB)
English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)
English (254 KB)
Tandem PPO Split Deductible 40-3000 70/50 English (PDF, 169 KB)
Spanish (PDF, 196 KB)
English
Hearing aid (PDF, 122 KB)
Base infertility 50% (PDF, 128 KB)
Additional infertility 50% (PDF, 128 KB)
Additional infertility 80% (PDF, 128 KB)
Additional infertility 95% (PDF, 127 KB)

Spanish
Hearing aid (PDF, 130 KB)
Base infertility 50% (PDF, 141 KB)
Additional infertility 50% (PDF, 141 KB)
Additional infertility 80% (PDF, 141 KB)
Additional infertility 95% (PDF, 141 KB)
English (254 KB)

Added Advantage Point of Service plans

Added Advantage POSSM plans Summary of Benefits Optional Benefits Disclosures
Added Advantage POSSM 
500-100/80/60

English (PDF, 431 KB)
Spanish (PDF, 452 KB)  

 

Chiropractic (PDF, 995 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture  (PDF, 1.7 MB)
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, 457 KB)

 

 

Not Marketed Added Advantage POSSM plans Summary of Benefits Optional Benefits Disclosures
Added Advantage POSSM 
300-100/90/70

English (PDF, 430 KB) 
Spanish (PDF, 451 KB)

 

Chiropractic (PDF, 995 KB)
Chiropractic and acupuncture (PDF, 994 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
Chiropractic (PDF, 1.7 MB)
Chiropractic and acupuncture  (PDF, 1.7 MB)
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, 457 KB)

 

Full EPO plans Summary of Benefits Optional benefits  Disclosures
Full EPO Zero Admit 20 English (PDF, 278 KB)
Spanish (PDF, 299 KB)

Hearing aid (PDF, 990 KB)
Base infertility 50% (PDF, 994 KB)
Additional infertility 50% (PDF, 994 KB)
Additional infertility 80% (PDF, 994 KB)
Additional infertility 95% (PDF, 994 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, 351 KB)
Full EPO Zero Admit 30 English (PDF, 278 KB)
Spanish (PDF, 299 KB)

Hearing aid (PDF, 990 KB)
Base infertility 50% (PDF, 994 KB)
Additional infertility 50% (PDF, 994 KB)
Additional infertility 80% (PDF, 994 KB)
Additional infertility 95% (PDF, 994 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, 351 KB)
Full EPO Per Admit 10-250 English (PDF, 278 KB)
Spanish (PDF, 299 KB)

Hearing aid (PDF, 990 KB)
Base infertility 50% (PDF, 994 KB)
Additional infertility 50% (PDF, 994 KB)
Additional infertility 80% (PDF, 994 KB)
Additional infertility 95% (PDF, 994 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, 351 KB)
Full EPO Facility Coinsurance 20-20% English (PDF, 278 KB)
Spanish (PDF, 299 KB)

Hearing aid (PDF, 990 KB)
Base infertility 50% (PDF, 994 KB)
Additional infertility 50% (PDF, 994 KB)
Additional infertility 80% (PDF, 994 KB)
Additional infertility 95% (PDF, 994 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, 351 KB)
Full EPO 25-1500 80% English (PDF, 278 KB)
Spanish (PDF, 299 KB)
Hearing aid (PDF, 990 KB)
Base infertility 50% (PDF, 994 KB)
Additional infertility 50% (PDF, 994 KB)
Additional infertility 80% (PDF, 994 KB)
Additional infertility 95% (PDF, 994 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, 351 KB)
Full EPO 25-2500 80% English (PDF, 278 KB)
Spanish (PDF, 299 KB)
Hearing aid (PDF, 990 KB)
Base infertility 50% (PDF, 994 KB)
Additional infertility 50% (PDF, 994 KB)
Additional infertility 80% (PDF, 994 KB)
Additional infertility 95% (PDF, 994 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, 351 KB)
Full EPO 10-250 90% English (PDF, 278 KB)
Spanish (PDF, 299 KB)
Hearing aid (PDF, 990 KB)
Base infertility 50% (PDF, 994 KB)
Additional infertility 50% (PDF, 994 KB)
Additional infertility 80% (PDF, 994 KB)
Additional infertility 95% (PDF, 994 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, 351 KB)
Full EPO 20-500 80% English (PDF, 278 KB)
Spanish (PDF, 299 KB)
Hearing aid (PDF, 990 KB)
Base infertility 50% (PDF, 994 KB)
Additional infertility 50% (PDF, 994 KB)
Additional infertility 80% (PDF, 994 KB)
Additional infertility 95% (PDF, 994 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, 351 KB)
Tandem EPO Plans Summary of Benefits Optional Benefits  Disclosures
Tandem EPO Zero Admit 20 English (PDF, 278 KB)
Spanish (PDF, 298 KB)
 

Hearing aid (PDF, 990 KB)
Base infertility 50% (PDF, 994 KB)
Additional infertility 50% (PDF, 994 KB)
Additional infertility 80% (PDF, 994 KB)
Additional infertility 95% (PDF, 994 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, 351 KB)
Tandem EPO Zero Admit 30 English (PDF, 278 KB)
Spanish (PDF, 298 KB)

 

Hearing aid (PDF, 990 KB)
Base infertility 50% (PDF, 994 KB)
Additional infertility 50% (PDF, 994 KB)
Additional infertility 80% (PDF, 994 KB)
Additional infertility 95% (PDF, 994 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, 351 KB)
Tandem EPO Per Admit 10-250 English (PDF, 278 KB)
Spanish (PDF, 298 KB)

 

Hearing aid (PDF, 990 KB)
Base infertility 50% (PDF, 994 KB)
Additional infertility 50% (PDF, 994 KB)
Additional infertility 80% (PDF, 994 KB)
Additional infertility 95% (PDF, 994 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, 351 KB)
Tandem EPO Facility Coinsurance 20-20% English (PDF, 278 KB)
Spanish (PDF, 298 KB)
 

Hearing aid (PDF, 990 KB)
Base infertility 50% (PDF, 994 KB)
Additional infertility 50% (PDF, 994 KB)
Additional infertility 80% (PDF, 994 KB)
Additional infertility 95% (PDF, 994 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, 351 KB)
Tandem EPO 25-1500 80% English (PDF, 282 KB)
Spanish (PDF, 305 KB)
Hearing aid (PDF, 990 KB)
Base infertility 50% (PDF, 994 KB)
Additional infertility 50% (PDF, 994 KB)
Additional infertility 80% (PDF, 994 KB)
Additional infertility 95% (PDF, 994 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, 351 KB)
Tandem EPO 25-2500 80% English (PDF, 282 KB)
Spanish (PDF, 305 KB)
Hearing aid (PDF, 990 KB)
Base infertility 50% (PDF, 994 KB)
Additional infertility 50% (PDF, 994 KB)
Additional infertility 80% (PDF, 994 KB)
Additional infertility 95% (PDF, 994 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, 351 KB)
Tandem EPO 20-500 80% English (PDF, 282 KB)
Spanish (PDF, 305 KB)
Hearing aid (PDF, 990 KB)
Base infertility 50% (PDF, 994 KB)
Additional infertility 50% (PDF, 994 KB)
Additional infertility 80% (PDF, 994 KB)
Additional infertility 95% (PDF, 994 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, 351 KB)
Tandem EPO 10-250 90% English (PDF, 282 KB)
Spanish (PDF, 305 KB)
Hearing aid (PDF, 990 KB)
Base infertility 50% (PDF, 994 KB)
Additional infertility 50% (PDF, 994 KB)
Additional infertility 80% (PDF, 994 KB)
Additional infertility 95% (PDF, 994 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, 351 KB)

Virtual Blue plans

Prescription drug options

Virtual BlueSM PPO and PPO Saving 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, 990 KB)
Base infertility 50% (PDF, 994 KB)
Additional infertility 50% (PDF, 994 KB)
Additional infertility 80% (PDF, 994 KB)
Additional infertility 95% (PDF, 994 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, 990 KB)
Base infertility 50% (PDF, 994 KB)
Additional infertility 50% (PDF, 994 KB)
Additional infertility 80% (PDF, 994 KB)
Additional infertility 95% (PDF, 994 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, 990 KB)
Base infertility 50% (PDF, 994 KB)
Additional infertility 50% (PDF, 994 KB)
Additional infertility 80% (PDF, 994 KB)
Additional infertility 95% (PDF, 994 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 Savings Embedded Deductible 5500 English (PDF, 223 KB)
Spanish (PDF, 262 KB)

Hearing aid (PDF, 990 KB)
Base infertility 50% (PDF, 994 KB)
Additional infertility 50% (PDF, 994 KB)
Additional infertility 80% (PDF, 994 KB)
Additional infertility 95% (PDF, 994 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 Savings Two-Tier Embedded Deductible 2500/3200/5000 English (PDF, 223 KB)
Spanish (PDF, 262 KB)

Hearing aid (PDF, 990 KB)
Base infertility 50% (PDF, 994 KB)
Additional infertility 50% (PDF, 994 KB)
Additional infertility 80% (PDF, 994 KB)
Additional infertility 95% (PDF, 994 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, 990 KB)
Base infertility 50% (PDF, 994 KB)
Additional infertility 50% (PDF, 994 KB)
Additional infertility 80% (PDF, 994 KB)
Additional infertility 95% (PDF, 994 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, 990 KB)
Base infertility 50% (PDF, 994 KB)
Additional infertility 50% (PDF, 994 KB)
Additional infertility 80% (PDF, 994 KB)
Additional infertility 95% (PDF, 994 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, 990 KB)
Base infertility 50% (PDF, 994 KB)
Additional infertility 50% (PDF, 994 KB)
Additional infertility 80% (PDF, 994 KB)
Additional infertility 95% (PDF, 994 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, 990 KB)
Base infertility 50% (PDF, 994 KB)
Additional infertility 50% (PDF, 994 KB)
Additional infertility 80% (PDF, 994 KB)
Additional infertility 95% (PDF, 994 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, 990 KB)
Base infertility 50% (PDF, 994 KB)
Additional infertility 50% (PDF, 994 KB)
Additional infertility 80% (PDF, 994 KB)
Additional infertility 95% (PDF, 994 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, 990 KB)
Base infertility 50% (PDF, 994 KB)
Additional infertility 50% (PDF, 994 KB)
Additional infertility 80% (PDF, 994 KB)
Additional infertility 95% (PDF, 994 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, 990 KB)
Base infertility 50% (PDF, 994 KB)
Additional infertility 50% (PDF, 994 KB)
Additional infertility 80% (PDF, 994 KB)
Additional infertility 95% (PDF, 994 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, 990 KB)
Base infertility 50% (PDF, 994 KB)
Additional infertility 50% (PDF, 994 KB)
Additional infertility 80% (PDF, 994 KB)
Additional infertility 95% (PDF, 994 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 EPO plans Summary of Benefits Optional benefits  Disclosures
Virtual BlueSM EPO 20-1000 80% English (PDF, 223 KB)
Spanish (PDF, 262 KB)

Hearing aid (PDF, 990 KB)
Base infertility 50% (PDF, 994 KB)
Additional infertility 50% (PDF, 994 KB)
Additional infertility 80% (PDF, 994 KB)
Additional infertility 95% (PDF, 994 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 EPO 20-1500 80% English (PDF, 223 KB)
Spanish (PDF, 262 KB)

Hearing aid (PDF, 990 KB)
Base infertility 50% (PDF, 994 KB)
Additional infertility 50% (PDF, 994 KB)
Additional infertility 80% (PDF, 994 KB)
Additional infertility 95% (PDF, 994 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 EPO 20-2000 70% English (PDF, 223 KB)
Spanish (PDF, 262 KB)

Hearing aid (PDF, 990 KB)
Base infertility 50% (PDF, 994 KB)
Additional infertility 50% (PDF, 994 KB)
Additional infertility 80% (PDF, 994 KB)
Additional infertility 95% (PDF, 994 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 EPO 20-250 80% English (PDF, 223 KB)
Spanish (PDF, 262 KB)

Hearing aid (PDF, 990 KB)
Base infertility 50% (PDF, 994 KB)
Additional infertility 50% (PDF, 994 KB)
Additional infertility 80% (PDF, 994 KB)
Additional infertility 95% (PDF, 994 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 EPO 20-250 90% English (PDF, 223 KB)
Spanish (PDF, 262 KB)

Hearing aid (PDF, 990 KB)
Base infertility 50% (PDF, 994 KB)
Additional infertility 50% (PDF, 994 KB)
Additional infertility 80% (PDF, 994 KB)
Additional infertility 95% (PDF, 994 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 EPO 20-500 80% English (PDF, 223 KB)
Spanish (PDF, 262 KB)

Hearing aid (PDF, 990 KB)
Base infertility 50% (PDF, 994 KB)
Additional infertility 50% (PDF, 994 KB)
Additional infertility 80% (PDF, 994 KB)
Additional infertility 95% (PDF, 994 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 EPO 20-750 80% English (PDF, 223 KB)
Spanish (PDF, 262 KB)

Hearing aid (PDF, 990 KB)
Base infertility 50% (PDF, 994 KB)
Additional infertility 50% (PDF, 994 KB)
Additional infertility 80% (PDF, 994 KB)
Additional infertility 95% (PDF, 994 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 EPO 50-1000 70% English (PDF, 223 KB)
Spanish (PDF, 262 KB)

Hearing aid (PDF, 990 KB)
Base infertility 50% (PDF, 994 KB)
Additional infertility 50% (PDF, 994 KB)
Additional infertility 80% (PDF, 994 KB)
Additional infertility 95% (PDF, 994 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 EPO 50-3000 60% English (PDF, 223 KB)
Spanish (PDF, 262 KB)

Hearing aid (PDF, 990 KB)
Base infertility 50% (PDF, 994 KB)
Additional infertility 50% (PDF, 994 KB)
Additional infertility 80% (PDF, 994 KB)
Additional infertility 95% (PDF, 994 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)

© California Physicians' Service DBA Blue Shield of California 1999-2024. 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.

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