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Benefit Modification Brochures
Benefit Modification Brochures
The Benefit Modifications offer a summary of specific benefit changes to your clients' plans in a convenient chart. Keep them up-to-date by downloading and sharing the fliers with your clients upon renewal. Copies will be included along with a complete list of legislative mandates and Blue Shield required changes in each renewal package delivered by your Blue Shield sales representative.
January 2017
Access+ HMO Plans Size
Access+ HMO® 15-500/Day Inpatient 24KB
Access+ HMO® 25-750/Day Inpatient 24KB
Access+ HMO® Admit Inpatient 20-250 24KB
Access+ HMO® Facility Coinsurance 15-20% 24KB
Access+ HMO® Facility Coinsurance 20-20% 24KB
Access+ HMO® Facility Coinsurance 25-25% 24KB
Access+ HMO® Facility Coinsurance 40-40% 24KB
Access+ HMO® Facility Deductible 15-10%/1500 24KB
Access+ HMO® Facility Deductible 20-25%/1500 24KB
Access+ HMO® Facility Deductible 30-30%/2000 24KB
Access+ HMO® Facility Deductible 40-40%/2000  24KB
Access+ HMO® Facility Deductible 40-40%/5800   
SaveNet HMO Plans Size
Access+ HMO® SaveNet Facility Coinsurance 15-20% 24KB
Access+ HMO® SaveNet Facility Coinsurance 20-20% 24KB
Access+ HMO® SaveNet Facility Coinsurance 25-25% 24KB
Access+ HMO® SaveNet Facility Coinsurance 40-40% 24KB
Access+ HMO® SaveNet Facility Deductible 15-10%/1500 24KB
Access+ HMO® SaveNet Facility Deductible 20-25%/1500 24KB
Access+ HMO® SaveNet Facility Deductible 30-30%/2000 24KB
Access+ HMO® SaveNet Facility Deductible 40-40%/2000 24KB
Access+ HMO® SaveNet Facility Deductible 40-40%/2000 24KB
Local Access+ HMO Plans Size
Local Access+ HMO® Zero Admit 10  24KB
Local Access+ HMO® Zero Admit 20  24KB
Local Access+ HMO® Zero Admit 30  24KB
Local Access+ HMO® Per Admit 10-250  24KB
Local Access+ HMO® Per Admit 25-750  24KB
Local Access+ HMO® Per Admit 40-1000  24KB
Local Access+ HMO® Facility Coinsurance 15-20% 24KB
Local Access+ HMO® Facility Coinsurance 20-20% 24KB
Local Access+ HMO® Facility Coinsurance 25-25% 24KB
Local Access+ HMO® Facility Coinsurance 40-40% 24KB
Local Access+ HMO® Facility Deductible 15-10%/1500 24KB
Local Access+ HMO® Facility Deductible 20-25%/1500 24KB
Local Access+ HMO® Facility Deductible 30-30%/2000 24KB
Local Access+ HMO® Facility Deductible 40-40%/2000 24KB
Local Access+ HMO® Facility Deductible 40-40%/5800 24KB

 

Trio ACO HMO plans Size
Trio ACO HMO® Facility Coinsurance 15-20% 24KB
Trio ACO HMO® Facility Coinsurance 20-20% 24KB
Trio ACO HMO® Facility Coinsurance 25-25% 24KB
Trio ACO HMO® Facility Coinsurance 40-40% 24KB
Trio ACO HMO® Facility Deductible 15-10%/1500 24KB
Trio ACO HMO® Facility Deductible 20-25%/1500 24KB
Trio ACO HMO® Facility Deductible 30-30%/2000 24KB
Trio ACO HMO® Facility Deductible 40-40%/2000 24KB
Trio ACO HMO® Facility Deductible 40-40%/2000 24KB
PPO Plans Size
Full PPO℠ 250-80/60 24KB
Full Value PPO℠ 250-90/70 24KB
Full PPO℠ No Network Deductible 10 100/50 24KB
Full PPO℠ Combined Deductible 20-200 90/70 24KB
Full PPO℠ Combined Deductible 25-250 90/60 24KB
Full PPO℠ Combined Deductible 30-500 90/60 24KB
Full PPO℠ Combined Deductible 35-500 80/60 24KB
Full PPO℠ Split Deductible 10-250 90/70 24KB
Full PPO℠ Split Deductible 15-500 90/60 24KB
Full PPO℠ Split Deductible 20-500 80/60 24KB
Full PPO℠ Split Deductible 25-750 80/60 24KB
Full PPO℠ Combined Deductible Value 15-1500 80/50 24KB
Full PPO℠ Combined Deductible Value 30-3000 80/50 24KB
Shield PPO℠ Combined Deductible Value 40-4000 80/50 24KB
Full PPO℠ No Network Deductible 20 100/50 24KB
Full PPO℠ Combined Deductible 10-250 90/70 24KB
PPO Savings Plans Size
Full PPO℠ Savings Individual Member Deductible 2600  24KB
Full PPO℠ Savings Individual Member Deductible 3000   24KB
Full PPO℠ Savings Individual Member Deductible 3500  24KB
Full PPO℠ Savings Individual Member Deductible 4000  24KB
Full PPO℠ Savings Individual Member Deductible 5500  24KB
January 2016
Access+ HMO Plans Size
Access+ HMO® Zero Admit 10  24KB
Access+ HMO® Zero Admit 20  24KB
Access+ HMO® Zero Admit 30  24KB
Access+ HMO® Per Admit 10-250  24KB
Access+ HMO® Per Admit 25-750  24KB
Access+ HMO® Per Admit 40-1000  24KB
Access+ HMO® Per Admit 20-500  24KB
Access+ HMO® 5-0 Inpatient  24KB
Access+ HMO® 10-200/Day Inpatient  24KB
Access+ HMO® 15-500/Day Inpatient  24KB
Access+ HMO® 10-100/Day Inpatient  24KB
Access+ HMO® 25-750/Day Inpatient  24KB
Access+ HMO® 40-1000/Day Inpatient  24KB
Access+ HMO® 15-500/Admit Inpatient  24KB
Access+ HMO® Admit Inpatient 20-250  24KB
Access+ HMO® 25-500/Admit Inpatient   24KB
Access+ HMO® 15-10%/1500 Facility Deductible  24KB
Access+ HMO® 30-20%/Zero Facility Deductible  24KB
Access+ HMO® 30-10%/1500 Facility Deductible  24KB
Access+ HMO® Facility Coinsurance 15-20%  24KB
Access+ HMO® Facility Coinsurance 20-20%  24KB
Access+ HMO® Facility Coinsurance 25-25%  24KB
Access+ HMO® Facility Coinsurance 40-40%  24KB
Access+ HMO® Facility Coinsurance 45-50%  24KB
Access+ HMO® Facility Deductible 15-10%/1500  24KB
Access+ HMO® Facility Deductible 20-25%/1500  24KB
Access+ HMO® Facility Deductible 30-30%/2000  24KB
Access+ HMO® Facility Deductible 40-40%/2000  24KB
SaveNet HMO Plans Size
Access+ HMO® SaveNet 15-500 Per Admit Inpatient  24KB
Access+ HMO® SaveNet Zero Admit 10  24KB
Access+ HMO® SaveNet Zero Admit 20  24KB
Access+ HMO® SaveNet Zero Admit 30  24KB
Access+ HMO® SaveNet Per Admit 10-250  24KB
Access+ HMO® SaveNet Per Admit 20-500  24KB
Access+ HMO® SaveNet Per Admit 25-750  24KB
Access+ HMO® SaveNet Per Admit 40-1000  24KB
Access+ HMO® SaveNet Facility Coinsurance 15-20%  24KB
Access+ HMO® SaveNet Facility Coinsurance 20-20%  24KB
Access+ HMO® SaveNet Facility Coinsurance 25-25%  24KB
Access+ HMO® SaveNet Facility Coinsurance 40-40%  24KB
Access+ HMO® SaveNet Facility Coinsurance 45-50%  24KB
Access+ HMO® SaveNet 10-50% Zero Facility Deductible  24KB
Access+ HMO® SaveNet 40-40% Zero Facility Deductible  24KB
Access+ HMO® SaveNet Facility Deductible 15-10%/1500  24KB
Access+ HMO® SaveNet Facility Deductible 20-25%/1500  24KB
Access+ HMO® SaveNet Facility Deductible 30-30%/2000  24KB
Access+ HMO® SaveNet Facility Deductible 40-40%/2000  24KB
Local Access+ HMO Plans Size
Local Access+ HMO® Zero Admit 10  24KB
Local Access+ HMO® Zero Admit 20  24KB
Local Access+ HMO® Zero Admit 30  24KB
Local Access+ HMO® Per Admit 10-250  24KB
Local Access+ HMO® Per Admit 20-500  24KB
Local Access+ HMO® Per Admit 25-750  24KB
Local Access+ HMO® Per Admit 40-1000  24KB
Local Access+ HMO® Facility Coinsurance 15-20%  24KB
Local Access+ HMO® Facility Coinsurance 20-20%  24KB
Local Access+ HMO® Facility Coinsurance 25-25%  24KB
Local Access+ HMO® Facility Coinsurance 40-40%  24KB
Local Access+ HMO® Facility Coinsurance 45-50%  24KB
Local Access+ HMO® Facility Deductible 15-10%/1500  24KB
Local Access+ HMO® Facility Deductible 20-25%/1500  24KB
Local Access+ HMO® Facility Deductible 30-30%/2000  24KB
Local Access+ HMO® Facility Deductible 40-40%/2000  24KB
Trio ACO HMO plans Size
Trio ACO HMO® Zero Admit 10  24KB
Trio ACO HMO® Zero Admit 20  24KB
Trio ACO HMO® Zero Admit 30  24KB
Trio ACO HMO® Per Admit 10-250  24KB
Trio ACO HMO® Per Admit 20-750  24KB
Trio ACO HMO® Per Admit 40-1000  24KB
Trio ACO HMO® Per Admit 20-500  24KB
Trio ACO HMO® Facility Coinsurance 15-20%  24KB
Trio ACO HMO® Facility Coinsurance 20-20%  24KB
Trio ACO HMO® Facility Coinsurance 25-25%  24KB
Trio ACO HMO® Facility Coinsurance 40-40%  24KB
Trio ACO HMO® Facility Coinsurance 45-50%  24KB
Trio ACO HMO® Facility Deductible 15-10%/1500  24KB
Trio ACO HMO® Facility Deductible 20-25%/1500  24KB
Trio ACO HMO® Facility Deductible 30-30%/2000  24KB
Trio ACO HMO® Facility Deductible 40-40%/2000  24KB
Active Choice Plans Size
Active Choice® Plan 500 80/50  24KB
Active Choice® Plan 750 80/60  24KB
Active Choice® Plan 750 70/50  24KB
Active Choice® Plan 750 70/50 1000 Deductible  24KB
Active Choice® Plan 500 80/50 1500 Deductible  24KB
POS Plans Size
Added Advantage POS℠ 250-100/80/50  24KB
Added Advantage POS℠ 500-100/80/60  24KB
Added Advantage POS℠ 300-100/90/70 24KB
PPO Plans Size
Shield Spectrum PPO℠ 500-90/70  24KB
Shield Spectrum PPO℠ 750 80/60  24KB
Full PPO℠ 250-80/60  24KB
Full Value PPO℠ 250-90/70  24KB
Shield Spectrum PPO℠ 500-80/60  24KB
Shield Spectrum PPO℠ 1000-80/50  24KB
Full PPO℠ 250-80/60 24KB
Shield Spectrum PPO℠ 0/500-90/70 Premier  24KB
Full PPO℠ Premier 250-90/70  24KB
Shield Spectrum PPO℠ 250-90/70 Standard  24KB
Full PPO℠ No Network Deductible 10 100/50  24KB
Full PPO℠ Combined Deductible 15-150 90/70  24KB
Full PPO℠ Combined Deductible 20-200 90/70  24KB
Full PPO℠ Combined Deductible 25-250 90/60  24KB
Full PPO℠ Combined Deductible 30-500 90/60  24KB
Full PPO℠ Combined Deductible 35-500 90/50  24KB
Full PPO℠ Combined Deductible 35-500 80/60  24KB
Full PPO℠ Split Deductible 10-250 90/70  24KB
Full PPO℠ Split Deductible 15-500 90/60  24KB
Full PPO℠ Split Deductible 20-500 80/60  24KB
Full PPO℠ Split Deductible 25-750 80/60  24KB
Full PPO℠ Split Deductible 35-1000 80/60  24KB
FullPPO℠ Combined Deductible Value 10-1000 90/70  24KB
Full PPO℠ Combined Deductible Value 15-1500 80/50  24KB
Full PPO℠ Combined Deductible Value 20-2000 80/50  24KB
FullPPO℠ Combined Deductible Value 25-2500 80/50  24KB
Full PPO℠ Combined Deductible Value 30-3000 80/50  24KB
Full PPO℠ Combined Deductible Value 35-3500 80/50  24KB
Shield PPO℠ Combined Deductible Value 40-4000 80/50  24KB
PPO Savings Plans Size
Full PPO℠ Savings Aggregate Deductible 1300/2600  24KB
Full PPO℠ Savings Aggregate Deductible 1500/3000  24KB
Full PPO℠ Savings Aggregate Deductible 1800/3600  24KB
Full PPO℠ Savings Aggregate Deductible 2250/4500  24KB
Full PPO℠ Savings Individual Member Deductible 2600  24KB
Full PPO℠ Savings Individual Member Deductible 3000   24KB
Full PPO℠ Savings Individual Member Deductible 3500  24KB
Full PPO℠ Savings Individual Member Deductible 4000  24KB
Full PPO℠ Savings Individual Member Deductible 5500  24KB
Full PPO℠ Savings Aggregate Deductible 1300/2600 with Value-Based Tier Drug Benefit  24KB
Fulll PPO℠ Savings Aggregate Deductible 1500/3000 with Value-Based Tier Drug Benefit  24KB
Full PPO℠ Savings Aggregate Deductible 2250/4500 with Value-Based Tier Drug Benefit  24KB
Shield Spectrum PPO℠ Plus 1500/3000  24KB
January 2015
Access+ HMO Plans Download Size
Access+ HMO® Zero Admit 10 English 24KB
Access+ HMO® Zero Admit 20 English 24KB
Access+ HMO® Zero Admit 30 English 24KB
Access+ HMO® Per Admit 10-250 English 24KB
Access+ HMO® Per Admit 25-750 English 24KB
Access+ HMO® Per Admit 40-1000 English 24KB
Access+ HMO® Per Admit 20-500 English 24KB
Access+ HMO® 5-0 Inpatient English 24KB
Access+ HMO® 10-200/Day Inpatient English 24KB
Access+ HMO® 15-500/Day Inpatient English 24KB
Access+ HMO® 10-100/Day Inpatient English 24KB
Access+ HMO® 25-750/Day Inpatient English 24KB
Access+ HMO® 40-1000/Day Inpatient English 24KB
Access+ HMO® 15-500/Admit Inpatient English 24KB
Access+ HMO® Inpatient 20-250 English 24KB
Access+ HMO® 25-500/Admit Inpatient  English 24KB
Access+ HMO® 15-10%/1500 Facility Deductible English 24KB
Access+ HMO® 30-20%/Zero Facility Deductible English 24KB
Access+ HMO® 30-10%/1500 Facility Deductible English 24KB
Access+ HMO® 10-20%/Zero Facility Deductible English 24KB
Access+ HMO® 40-40%/1000 Facility Deductible English 24KB
Access+ HMO® Facility Coinsurance 15-20% English 24KB
Access+ HMO® Facility Coinsurance 20-20% English 24KB
Access+ HMO® Facility Coinsurance 25-25% English 24KB
Access+ HMO® Facility Coinsurance 40-40% English 24KB
Access+ HMO® Facility Coinsurance 45-50% English 24KB
Access+ HMO® Facility Deductible 15-10%/1500 English 24KB
Access+ HMO® Facility Deductible 20-25%/1500 English 24KB
Access+ HMO® Facility Deductible 30-30%/2000 English 24KB
Access+ HMO® Facility Deductible 40-40%/2000 English 24KB
SaveNet HMO Plans Download Size
Access+ HMO® SaveNet 15-500 Per Admit Inpatient English 24KB
Access+ HMO® SaveNet Zero Admit 10 English 24KB
Access+ HMO® SaveNet Zero Admit 20 English 24KB
Access+ HMO® SaveNet Zero Admit 30 English 24KB
Access+ HMO® SaveNet Per Admit 10-250 English 24KB
Access+ HMO® SaveNet Per Admit 20-500 English 24KB
Access+ HMO® SaveNet Per Admit 25-750 English 24KB
Access+ HMO® SaveNet Per Admit 40-1000 English 24KB
Access+ HMO® SaveNet Facility Coinsurance 15-20% English 24KB
Access+ HMO® SaveNet Facility Coinsurance 20-20% English 24KB
Access+ HMO® SaveNet Facility Coinsurance 25-25% English 24KB
Access+ HMO® SaveNet Facility Coinsurance 40-40% English 24KB
Access+ HMO® SaveNet Facility Coinsurance 45-50% English 24KB
Access+ HMO® SaveNet 10-50% Zero Facility Deductible English 24KB
Access+ HMO® SaveNet 40-40% Zero Facility Deductible English 24KB
Access+ HMO® SaveNet Facility Deductible 15-10%/1500 English 24KB
Access+ HMO® SaveNet Facility Deductible 20-25%/1500 English 24KB
Access+ HMO® SaveNet Facility Deductible 30-30%/2000 English 24KB
Access+ HMO® SaveNet Facility Deductible 40-40%/2000 English 24KB
Local Access+ HMO Plans Download Size
Local Access+ HMO® Zero Admit 10 English 24KB
Local Access+ HMO® Zero Admit 20 English 24KB
Local Access+ HMO® Zero Admit 30 English 24KB
Local Access+ HMO® Per Admit 10-250 English 24KB
Local Access+ HMO® Per Admit 20-500 English 24KB
Local Access+ HMO® Per Admit 25-750 English 24KB
Local Access+ HMO® Per Admit 40-1000 English 24KB
Local Access+ HMO® Facility Coinsurance 15-20% English 24KB
Local Access+ HMO® Facility Coinsurance 20-20% English 24KB
Local Access+ HMO® Facility Coinsurance 25-25% English 24KB
Local Access+ HMO® Facility Coinsurance 40-40% English 24KB
Local Access+ HMO® Facility Coinsurance 45-50% English 24KB
Local Access+ HMO® Facility Deductible 15-10%/1500 English 24KB
Local Access+ HMO® Facility Deductible 20-25%/1500 English 24KB
Local Access+ HMO® Facility Deductible 30-30%/2000 English 24KB
Local Access+ HMO® Facility Deductible 40-40%/2000 English 24KB
Local Access+ HMO® 30-20%/Zero Facility Deductible English 24KB
Local Access+ HMO® 20-250/Admit Inpatient English 24KB
Local Access+ HMO® 15-500/Admit Inpatient English 24KB
Local Access+ HMO® 25-750/Day Inpatient English 24KB
Local Access+ HMO® 40-1000/Day Inpatient English 24KB
Active Choice Plans Download Size
Active Choice® Plan 500 English 24KB
Active Choice® Plan 500 Foundation English 24KB
Active Choice® Plan 750 English 24KB
Active Choice® Plan 750 Foundation English 24KB
Active Choice® Plan 750 70/50 English 24KB
Active Choice® Plan 750 1000 Deductible English 24KB
Active Choice® Plan 750 1000 Deductible Foundation English 24KB
Active Choice® Plan 500 1500 Deductible English 24KB
Active Choice® Plan 500 1500 Deductible Foundation English 24KB
POS Plans Download Size
Added Advantage POSSM 300-100/80/60 English 24KB
Added Advantage POSSM 500-100/80/60 English 24KB
Added Advantage POSSM 300-100/90/70 Standard English 24KB
Added Advantage POSSM 300-100/90/70 Premier English 24KB
Added Advantage POSSM 300-100/70 English 24KB
Added Advantage POSSM 250-100/80/50 English 24KB
PPO Plans Download Size
Shield Spectrum PPO℠ 500-90/70 English 24KB
Shield Spectrum PPO℠ 500-90/70 Foundation English 24KB
Shield Spectrum PPO℠ 750 80/60 English 24KB
Shield Spectrum PPO℠ 0/500-90/70 Standard English 24KB
Shield Spectrum PPO℠ 0/500-90/70 Standard Foundation English 24KB
Shield Spectrum PPO℠ 250-80/60 English 24KB
Shield Spectrum PPO℠ 250-80/60 Foundation English 24KB
Shield Spectrum PPO℠ 250-90/70 Value English 24KB
Shield Spectrum PPO℠ 500-80/60 English 24KB
Shield Spectrum PPO℠ 1000-80/50 English 24KB
Shield Spectrum PPO℠ 250-80/60 Standard English 24KB
Shield Spectrum PPO℠ 0/500-90/70 Premier English 24KB
Shield Spectrum PPO℠ 250-90/70 Premier English 24KB
Shield Spectrum PPO℠ 250-90/70 Standard English 24KB
Shield Spectrum PPO℠ 1000-80/60 Premier English 24KB
Shield Spectrum PPO℠ 1000-80/60 Premier Foundation English 24KB
Shield Spectrum PPO℠ 250 70/50 Foundation English 24KB
Shield Spectrum PPO℠ 1500 80/50 English 24KB
Shield Spectrum PPO℠ 1800 80/50 English 24KB
Shield PPO℠ Combined Deductible 10-0 100/50 English 24KB
Shield PPO℠ Combined Deductible 15-150 90/70 English 24KB
Shield PPO℠ Combined Deductible 20-200 90/70 English 24KB
Shield PPO℠ Combined Deductible 25-250 90/60 English 24KB
Shield PPO℠ Combined Deductible 25-250 90/60 Foundation English 24KB
Shield PPO℠ Combined Deductible 30-500 90/60 English 24KB
Shield PPO℠ Combined Deductible 35-500 90/50 English 24KB
Shield PPO℠ Combined Deductible 35-500 80/60 English 24KB
Shield PPO℠ Combined Deductible 35-500 90/50 Foundation English 24KB
Shield PPO℠ Split Deductible 10-250 90/70 English 24KB
Shield PPO℠ Split Deductible 15-500 90/60 English 24KB
Shield PPO℠ Split Deductible 20-500 80/60 English 24KB
Shield PPO℠ Split Deductible 25-750 80/60 English 24KB
Shield PPO℠ Split Deductible 35-1000 80/60 English 24KB
Shield PPO℠ Combined Deductible Value 10-1000 90/70 English 24KB
Shield PPO℠ Combined Deductible Value 15-1500 80/50 English 24KB
Shield PPO℠ Combined Deductible Value 20-2000 80/50 English 24KB
Shield PPO℠ Combined Deductible Value 25-2500 80/50 English 24KB
Shield PPO℠ Combined Deductible Value 30-3000 80/50 English 24KB
Shield PPO℠ Combined Deductible Value 35-3500 80/50 English 24KB
Shield PPO℠ Combined Deductible Value 40-4000 80/50 English 24KB
PPO HSA and PSP Plans Download Size
Shield PPO Savings Plus Aggregate Deductible 1300/2600 English 24KB
Shield PPO Savings Plus Aggregate Deductible 1500/3000 English A4324KB
Shield PPO Savings Plus Aggregate Deductible 1800/3600 English 24KB
Shield PPO Savings Plus Aggregate Deductible 1800/3600 Foundation English 24KB
Shield PPO Savings Plus Aggregate Deductible 2250/4500 English 24KB
Shield PPO Savings Plus Individual Member Deductible 2600 English 24KB
Shield PPO Savings Plus Individual Member Deductible 3000  English 24KB
Shield PPO Savings Plus Individual Member Deductible 3500 English 24KB
Shield PPO Savings Plus Individual Member Deductible 4000 English 24KB
Shield PPO Savings Plus Individual Member Deductible 5500 English 24KB
Shield Spectrum PPO℠ Savings Plus 1500/3000 English 24KB
Shield Spectrum PPO℠ Savings Plus 3000 English 24KB
Shield Savings℠ Plus 2400  English 24KB
Shield Savings℠ Plus 2400 Foundation  English 24KB
Shield Savings℠ Plus 4000 English 24KB
Shield Savings℠ Plus 4000 Foundation English 24KB
January 2014
Form Download Size
HMO Plans
HMO Facility Deductible 15-10%/1500 English 24KB
HMO Facility Deductible 20-25%/1500 English 24KB
HMO Facility Deductible 30-30%/2000 English 24KB
HMO Facility Deductible 40-40%/2000 English 24KB
HMO SaveNet Zero Admit 10 English 24KB
HMO SaveNet Zero Admit 20 English 24KB
HMO SaveNet Zero Admit 30 English 24KB
HMO SaveNet Per Admit 20-500 English 24KB
HMO SaveNet Per Admit 25-750 English 24KB
HMO SaveNet Per Admit 40-1000 English 24KB
HMO SaveNet Facility Coinsurance 20-20% English 24KB
HMO SaveNet Facility Coinsurance 25-25% English 24KB
HMO SaveNet Facility Coinsurance 40-40% English 24KB
HMO SaveNet Facility Coinsurance 45-50% English 24KB
HMO SaveNet Facility Deductible 15-10%/1500 English 24KB
HMO SaveNet Facility Deductible 20-25%/1500 English 24KB
HMO SaveNet Facility Deductible 30-30%/2000 English 24KB
HMO SaveNet Facility Deductible 40-40%/2000 English 24KB
Local Access+ HMO Zero Admit 10 English 24KB
Local Access+ HMO Zero Admit 20 English 24KB
Local Access+ HMO Zero Admit 30 English 24KB
Local Access+ HMO Per Admit 10-250 English 24KB
Local Access+ HMO Per Admit 20-500 English 24KB
Local Access+ HMO Per Admit 40-1000 English 24KB
Local Access+ HMO Facility Coinsurance 20-20% English 24KB
Local Access+ HMO Facility Coinsurance 25-25% English 24KB
Local Access+ HMO Facility Coinsurance 45-50% English 24KB
Local Access+ HMO Facility Deductible 15-10%/1500 English 24KB
Local Access+ HMO Facility Deductible 20-25%/1500 English 24KB
Local Access+ HMO Facility Deductible 30-30%/2000 English 24KB
Local Access+ HMO Facility Deductible 40-40%/2000 English 24KB
HMO Facility Coinsurance 20-20% English 24KB
Added Advantage POSSM Plans 
POS 250 - 100/80/50 English 36KB
POS 300 - 100/70
English 36KB
POS 300 - 100/90/70 Premier  English 36KB
POS 300 - 100/90/70 Standard English  36KB
POS 300 - 100/80/60 English 36KB
POS 500 - 100/80/60 English 36KB
POS 500 - 100/90/70 English 36KB
Shield Spectrum PPOSM Plans  
PPO 250 - 90/70 Value English 121KB
PPO 250 - 80/60 English 122KB
PPO 250 - 80/60 Standard English 120KB
PPO 250 - 90/70 Premier English 121KB
Shield SavingsSM Plus Plans
Shield SavingsSM Plus Aggregate Deductible 1250/2500 English 25KB
Shield SavingsSM Plus Individual Member Deductible 4000 English 25KB
Smart ShieldSM PPO Plans
Shield PPO Combined Deductible 15-150 90/70 English 28KB
Shield PPO Combined Deductible 20-200 90/70 English 28KB
Shield PPO Combined Deductible 25-250 90/60 English 28KB
Shield PPO Combined Deductible 30-500 90/60 English 28KB
Shield PPO Combined Deductible 35-500 90/50 English 28KB
Shield PPO Split Deductible 10-250 90/70 English 28KB
Shield PPO Split Deductible 15-500 90/60 English 28KB
Shield PPO Split Deductible 20-500 80/60 English 28KB
Shield PPO Split Deductible 25-750 80/60 English 28KB
Shield PPO Split Deductible 35-1000 80/60 English 28KB
Shield PPO Combined Deductible Value 15-1500 80/50 English 28KB
Shield PPO Combined Deductible Value 20-2000 80/50 English 28KB
Shield PPO Combined Deductible Value 30-3000 80/50 English 28KB
Shield PPO Combined Deductible Value 40-4000 80/50 English 28KB
Active Choice® Plans1
Active Choice 500 English  27KB
Active Choice 750 English  26KB
Foundation Plans1 
Active Choice 750 Foundation English 19KB
Shield SavingsSM  Plus Plan 1800 Foundation English 32KB
PPO 0/500 - 90/70 Standard Foundation English 34KB
PPO 250 - 90/70 Value Foundation English 33KB
PPO 250 - 80/60 Foundation English 34KB
PPO 500 - 80/60 Foundation English 34KB
PPO 500 - 90/70 Foundation English 34KB
Shield SavingsSM  Plus Plan 2400 Individual/4800 Family Foundation English 33KB
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Closed to new business effective 1/1/13, renewing groups only
Form Download Size
Access+HMO Plans (closed to new business effective 1/1/13, renewing groups only)
HMO 5 - 0 Inpatient English  24KB
HMO 10 - 0/Inpatient      English 24KB
HMO 10 - 100/Day Inpatient English  24KB
HMO 10 -200/Day Inpatient English  24KB
HMO 10 - 250/Admit Inpatient      English  24KB
HMO SaveNet 10 - 250/Admit Inpatient English 19KB
HMO 10 - 1000/Admit Inpatient English 24KB
HMO 10 - 20%/Zero Facility Deductible English 24KB
HMO 15 - 500/Admit Inpatient English  24KB
HMO SaveNet 15 - 500/Admit Inpatient English 19KB
HMO 15 - 500/Day Inpatient English  24KB
HMO 15 - 1000/Admit Inpatient English  24KB
HMO 15 - 10%/1500 Facility Deductible English 24KB
HMO 15 - 20%/Zero Facility Deductible English 24KB
HMO SaveNet 15 - 20%/Zero Facility Deductible English 19KB
HMO 20 - 500/Admit Inpatient English 24KB
HMO 20 - 1000/Admit Inpatient English  24KB
HMO 20 - 25%/Zero Facility Deductible English 24KB
HMO 25 - 500/Admit Inpatient English  22KB
HMO 25 - 750/Day Inpatient English 24KB
HMO 25 - 1000/Admit Inpatient English  24KB
HMO 30 - 10%/1500 Facility Deductible English  24KB
HMO 30 - 20%/Zero Facility Deductible English 24KB
HMO 40 - 1000/Day Inpatient English  24KB
HMO 40 - 40%/Zero Facility Deductible English 24KB
HMO SaveNet 40 - 40%/Zero Facility Deductible English 24KB
HMO 45 - 50%/Zero Facility Deductible English 24KB
HMO SaveNet 10 - 50%/Zero Facility Deductible English 24KB
Local Access+ HMO® (Closed to new business effective 1/1/13, renewing groups only)
Local Access+ HMO 15 -500/Admit Inpatient English  24KB
Local Access+ HMO 20 - 250/Admit Inpatient      English 24KB
Local Access+ HMO 15 - 20%/Zero Facility Deductible English  24KB
Local Access+ HMO 30 - 20%/Zero Facility Deductible English  24KB
Local Access+ HMO 45- 50%/ Zero Facility Deductible      English  24KB
Shield Spectrum PPOSM Plans (closed to new business effective 1/1/13, renewing groups only)
PPO 0/500 - 90/70 Standard English 41KB
PPO 0/500 - 90/70 Premier English 44KB
PPO 0/500  - 100/50 English 44KB
PPO 250 - 90/70 Standard English  42KB
PPO 500 - 80/60 English  38KB
PPO 500 - 90/70 English  41KB
PPO 1000 - 80/50 English 38KB
PPO 1000 - 80/60 English 39KB
PPO 1000 - 80/60 Premier1 English 42KB
PPO 1000 - 90/70 English  41KB
PPO 1500 - 80/60 English  38KB
PPO 1500 - 90/70 English  38KB
PPO 2000 - 70/501 English  42KB
PPO 3000 - 80/501 English  38KB
PPO 3000 - 80/601 English 42KB
Shield SavingsSM Plus Plans (closed to new business effective 1/1/13, open to renewing groups)
Shield SavingsSM Plus Plan 15001 English  32KB
Shield SavingsSM Plus Plan 18001 English 32KB
Shield SavingsSM Plus Plan 2400 Individual/4800 Family1 English 33KB
Shield SavingsSM Plus Plan 2250 English  22KB
Shield SavingsSM Plus Plan 2600 Individual/5200 Family1 English  33KB
Shield SavingsSM Plus Plan 3000 Individual/6000 Family English 33KB
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January 2013
 
Form Download Size
Access+HMO Plans (closed to new business effective 1/1/13, renewing groups only)
HMO 5 - 0 Inpatient English  24KB
HMO 10 - 0/Inpatient      English 24KB
HMO 10 - 100/Day Inpatient English  24KB
HMO 10 -200/Day Inpatient English  24KB
HMO 10 - 250/Admit Inpatient      English  24KB
HMO SaveNet 10 - 250/Admit Inpatient English 19KB
HMO 10 - 1000/Admit Inpatient English 24KB
HMO 10 - 20%/Zero Facility Deductible English 24KB
HMO 15 - 500/Admit Inpatient English  24KB
HMO SaveNet 15 - 500/Admit Inpatient English 19KB
HMO 15 - 500/Day Inpatient English  24KB
HMO 15 - 1000/Admit Inpatient English  24KB
HMO 15 - 10%/1500 Facility Deductible English 24KB
HMO 15 - 20%/Zero Facility Deductible English 24KB
HMO SaveNet 15 - 20%/Zero Facility Deductible English 19KB
HMO 20 - 500/Admit Inpatient English 24KB
HMO 20 - 1000/Admit Inpatient English  24KB
HMO 20 - 250/Admit Inpatient English  22KB
HMO 20 - 25%/Zero Facility Deductible English 24KB
HMO 25 - 500/Admit Inpatient English  22KB
HMO 25 - 750/Day Inpatient English 24KB
HMO 25 - 1000/Admit Inpatient English  24KB
HMO 30 - 10%/1500 Facility Deductible English  24KB
HMO 30 - 20%/Zero Facility Deductible English 24KB
HMO 40 - 1000/Day Inpatient English  24KB
HMO 40 - 40%/Zero Facility Deductible English 24KB
HMO SaveNet 40 - 40%/Zero Facility Deductible English 24KB
HMO 45 - 50%/Zero Facility Deductible English 24KB
HMO SaveNet 10 - 50%/Zero Facility Deductible English 24KB
Local Access+ HMO® (Closed to new business effective 1/1/13, renewing groups only)
Local Access+ HMO 15 -500/Admit Inpatient English  24KB
Local Access+ HMO 20 - 250/Admit Inpatient      English 24KB
Local Access+ HMO 15 - 20%/Zero Facility Deductible English  24KB
Local Access+ HMO 30 - 20%/Zero Facility Deductible English  24KB
Local Access+ HMO 45- 50%/ Zero Facility Deductible      English  24KB
Access Baja® HMO 
Access Baja HMO Plan 5 English 36KB
Access Baja HMO Plan 10
English 36KB
Added Advantage POSSM Plans 
POS 250 - 100/80/50 English 36KB
POS 300 - 100/70
English 36KB
POS 300 - 100/90/70 Premier  English 36KB
POS 300 - 100/90/70 Standard English  36KB
POS 300 - 100/80/60 English 36KB
POS 500 - 100/80/60 English 36KB
POS 500 - 100/90/70 English 36KB
Shield Spectrum PPOSM Plans (For groups of 51 and above)
PPO 0/500 - 90/70 Standard English 41KB
PPO 0/500 - 90/70 Premier English 44KB
PPO 0/500  - 100/50 English 44KB
PPO 250 - 80/60 English 38KB
PPO 250 - 80/60 Standard English 33KB
PPO 250 - 90/70 Value English  38KB
PPO 250 - 90/70 Standard English  42KB
PPO 250 - 90/70 Premier
English  42KB
PPO 500 - 80/60
English  38KB
PPO 500 - 90/70 English  41KB
PPO 1000 - 80/50 English 38KB
PPO 1000 - 80/60 English 39KB
PPO 1000 - 80/60 Premier1 English 42KB
PPO 1000 - 90/70 English  41KB
PPO 1500 - 80/60 English  38KB
PPO 1500 - 90/70 English  38KB
PPO 2000 - 70/501 English  42KB
PPO 3000 - 80/501 English  38KB
PPO 3000 - 80/601 English 42KB
Shield SavingsSM Plus Plan
Shield SavingsSM Plus Plan 15001 English  32KB
Shield SavingsSM Plus Plan 18001 English 32KB
Shield SavingsSM Plus Plan 2400 Individual/4800 Family1 English 33KB
Shield SavingsSM Plus Plan 2250 English  22KB
Shield SavingsSM Plus Plan 2600 Individual/5200 Family1 English  33KB
Shield SavingsSM Plus Plan 3000 Individual/6000 Family English 33KB
Active Choice® Plans1
Active Choice 500 English  27KB
Active Choice 750 English  26KB
Foundation Plans1 
Active Choice 750 Foundation English 19KB
Shield SavingsSM  Plus Plan 1800 Foundation English 32KB
PPO 0/500 - 90/70 Standard Foundation English 34KB
PPO 250 - 90/70 Value Foundation English 33KB
PPO 250 - 80/60 Foundation English 34KB
PPO 500 - 80/60 Foundation English 34KB
PPO 500 - 90/70 Foundation English 34KB
Shield SavingsSM  Plus Plan 2400 Individual/4800 Family Foundation English 33KB
Core Flex PPO Plan Package (closed to new business, renewing groups only)
Core Flex Basic English 37KB
Core Flex 70/50 English 37KB
Core Flex 80/60 English 37KB
Core Flex 90/70 English 37KB
Core Flex 90/70 Premier English 37KB
Core Flex HMO Plan Package
Core Flex Basic HMO 45 English 37KB
Core Flex HMO 40 English 37KB
Core Flex HMO 30 English 37KB
Core Flex HMO 20 English 37KB
 
 
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1. Underwritten by Blue Shield of California Life and Health Insurance Company.
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