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January 2008 Benefit Summaries
Uniform Health Plan Benefits and Coverage Matrices

These benefit summaries are effective beginning January 1, 2008 for groups of 51 or more employees.

Please contact your Blue Shield representative to learn about additional optional benefits that are available.

 

  • Access+ HMO® Plans
  • Added Advantage POSSM Plans
  • Shield Spectrum PPOSM Plans
  • Shield Spectrum PPO Savings Plus Plans
  • Active ChoiceSM Plans*
  • Access Baja® Plans
  • Closed Plans - Available to existing renewing groups only
  •  

    Access+ HMO® Plans
    Plan Name Benefit Summaries Prescription Drug Coverage
    HMO 5 - 0 Inpatient English (PDF, 63KB)
    Spanish (PDF, 65KB)
    Drug Coverage Options
    HMO 10 - 0 Inpatient English (PDF, 63KB)
    Spanish (PDF, 65KB)
    Drug Coverage Options
    HMO 10 - 100/Day Inpatient English (PDF, 62KB)
    Spanish (PDF, 65KB)
    Drug Coverage Options
    HMO 10 - 200/Day Inpatient English (PDF, 62KB)
    Spanish (PDF, 64KB)
    Drug Coverage Options
    HMO 10 - 250/Admit Inpatient English (PDF, 63KB)
    Spanish (PDF, 73KB)
    Drug Coverage Options
    HMO 10 - 20% Zero Facility Deductible English (PDF, 62KB)
    Spanish (PDF, 64KB)
    Drug Coverage Options
    HMO 15 - 500/Day Inpatient English (PDF, 62KB)
    Spanish (PDF, 65KB)
    Drug Coverage Options
    HMO 15 - 500/Admit Inpatient English (PDF, 64KB)
    Spanish (PDF, 64KB)
    Drug Coverage Options
    HMO 15 - 10%/1500 Facility Deductible English (PDF, 63KB)
    Spanish (PDF, 65KB)
    Drug Coverage Options
    HMO 15 - 20%/Zero Facility Deductible English (PDF, 63KB)
    Spanish (PDF, 65KB)
    Drug Coverage Options
    HMO 20 - 250/Admit Inpatient English (PDF, 63KB)
    Spanish (PDF, 64KB)
    Drug Coverage Options
    HMO 20 - 500/Admit Inpatient English (PDF, 64KB)
    Spanish (PDF, 65KB)
    Drug Coverage Options
    HMO 20 - 25% Zero Facility Deductible English (PDF, 63KB)
    Spanish (PDF, 65KB)
    Drug Coverage Options
    HMO 25 - 500/Admit Inpatient English (PDF, 63KB)
    Spanish (PDF, 65KB)
    Drug Coverage Options
    HMO 25 - 750/Day Inpatient English (PDF, 62KB)
    Spanish (PDF, 65KB)
    Drug Coverage Options
    HMO 30 - 10%/1500 Facility Deductible English (PDF, 63KB)
    Spanish (PDF, 64KB)
    Drug Coverage Options
    HMO 30 - 20%/Zero Facility Deductible English (PDF, 63KB)
    Spanish (PDF, 64KB)
    Drug Coverage Options
    HMO 40 - 1000/Day Inpatient English (PDF, 62KB)
    Spanish (PDF, 65KB)
    Drug Coverage Options
    HMO 40 - 40%/Zero Facility Deductible English (PDF, 41KB)
    Spanish (PDF, 65KB)
    Drug Coverage Options
    Access+ HMO SaveNet 10 - 250/Admit Inpatient English (PDF, 64KB)
    Spanish (PDF, 72KB)
    Drug Coverage Options
    Access+ HMO SaveNet 15 - 20% English (PDF, 64KB)
    Spanish (PDF, 66KB)
    Drug Coverage Options
    Access+ HMO SaveNet 15 - 500/Admit Inpatient English (PDF, 43KB)
    Spanish (PDF, 66KB)
    Drug Coverage Options
    Optional Benefits

    For Access+ HMO plans

    Substance Abuse
    English (PDF, 32KB)
    Spanish (PDF, 38KB)

    Chiropractic
    English (PDF, 88KB)
    Spanish (PDF, 79KB)

    Chiropractic & Acupuncture
    English (PDF, 37KB)
    Spanish (PDF, 90KB)

    Infertility
    English (PDF, 29KB)
    Spanish (PDF, 90KB)

     

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    Added Advantage POSSM Plans
    Plan Name Benefit Summaries Prescription Drug Coverage
    POS 250 - 100/80/50 English (PDF, 100KB)
    Spanish (PDF, 84KB)
    Drug Coverage Options
    POS 300 - 100/70 English (PDF, 95KB)
    Spanish (PDF, 82KB)
    Drug Coverage Options
    POS 300 - 100/80/60 English (PDF, 98KB)
    Spanish (PDF, 81KB)
    Drug Coverage Options
    POS 300 - 100/90/70 Standard English (PDF, 98KB)
    Spanish (PDF, 80KB)
    Drug Coverage Options
    POS 300 - 100/90/70 Premier English (PDF, 99KB)
    Spanish (PDF, 76KB)
    Drug Coverage Options
    POS 500 - 100/80/60 English (PDF, 100KB)
    Spanish (PDF, 81KB)
    Drug Coverage Options
    Optional Benefits

    For Added Advantage POSSM Plans

    Substance Abuse
    English (PDF, 25KB)
    Spanish (PDF, 33KB)

    Chiropractic
    English (PDF, 88KB)
    Spanish (PDF, 79KB)

    Chiropractic & Acupuncture
    English (PDF, 37KB)
    Spanish (PDF, 90KB)

    Infertility
    English (PDF, 29KB)
    Spanish (PDF, 90KB)

     

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    Shield Spectrum PPOSM Plans
    Plan Name Benefit Summaries Prescription Drug Options
    PPO 0/500 - 90/70 Standard English (PDF, 69KB)
    Spanish (PDF, 51KB)
    Drug Coverage Options
    PPO 0/500 - 90/70 Premier English (PDF, 68KB)
    Spanish (PDF, 52KB)
    Drug Coverage Options
    PPO Plan 250 - 80/60 English (PDF, 68KB)
    Spanish (PDF, 53KB)
    Drug Coverage Options
    PPO Plan 250 - 80/60 Standard English (PDF, 68KB)
    Spanish (PDF, 53KB)
    Drug Coverage Options
    PPO 250 - 90/70 Value English (PDF, 68KB)
    Spanish (PDF, 52KB)
    Drug Coverage Options
    PPO 250 - 90/70 Standard English (PDF, 68KB)
    Spanish (PDF, 50KB)
    Drug Coverage Options
    PPO 250 - 90/70 Premier English (PDF, 68KB)
    Spanish (PDF, 51KB)
    Drug Coverage Options
    PPO 500 - 80/60 English (PDF, 69KB)
    Spanish (PDF, 51KB)
    Drug Coverage Options
    PPO 500 - 90/70 English (PDF, 68KB)
    Spanish (PDF, 52KB)
    Drug Coverage Options
    PPO 1000 - 80/60 Premier* English (PDF, 68KB)
    Spanish (PDF, 52KB)
    Drug Coverage Options
    PPO 1000 - 90/70 English (PDF, 68KB)
    Spanish (PDF, 51KB)
    Drug Coverage Options
    PPO 2000 - 70/50* English (PDF, 67KB)
    Spanish (PDF, 51KB)
    Drug Coverage Options
    PPO 3000 - 80/60* English (PDF, 68KB)
    Spanish (PDF, 52KB)
    Drug Coverage Options
    Shield Spectrum PPO 500 80/60 Foundation* English (PDF, 68KB)
    Spanish (PDF, 52KB)
    Drug Coverage Options
    Shield Spectrum PPO 0/500 90/70 Standard - Foundation* English (PDF, 69KB)
    Spanish (PDF, 52KB)
    Drug Coverage Options
    Shield Spectrum PPO 250 80/60 - Foundation* English (PDF, 68KB)
    Spanish (PDF, 53KB)
    Drug Coverage Options
    Shield Spectrum PPO 500 90/70 - Foundation* English (PDF, 68KB)
    Spanish (PDF, 53KB)
    Drug Coverage Options
    Shield Spectrum PPO 250 90/70 Value - Foundation* English (PDF, 68KB)
    Spanish (PDF, 53KB)
    Drug Coverage Options
    Optional Benefits

    For PPO 250-80/60, PPO 250-80/60 Standard, and PPO 500-80/60

    Substance Abuse
    English (PDF, 31KB)
    Spanish (PDF, 41KB)

    Infertility
    English (PDF, 29KB)
    Spanish (PDF, 90KB)

    For PPO 0/500-90/70 Premier, PPO 0/500-90/70 Standard, PPO 250-90/70 Premier, PPO 250-90/70 Standard, PPO 250-90/70 Value, PPO 500-90/70 and PPO 1000-90/70

    Substance Abuse
    English (PDF, 23KB)
    Spanish (PDF, 37KB)

    Infertility
    English (PDF, 29KB)
    Spanish (PDF, 90KB)

    For PPO 0/500-90/70 Standard Foundation**, PPO 250-80/60 Foundation**, PPO 250-90/70 Value Foundation**, PPO 500-80/60 Foundation**, PPO 500-90/70 Foundation**, PPO 1000-80/60 Premier, PPO 2000-70/50 and PPO 3000-80/60

    Substance Abuse
    English (PDF, 34KB)
    Spanish (PDF, 44KB)

    Infertility
    English (PDF, 29KB)
    Spanish (PDF, 90KB)

     

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    Shield Spectrum PPO Savings Plus Plans
    Plan Name Benefit Summaries Disclosures
    PPO Savings Plus 1500* English (PDF, 70KB)
    Spanish (PDF, 55KB)
    English (PDF, 237KB)
    Spanish (PDF, 275KB)
    PPO Savings Plus 2400 Individual/4800 Family* English (PDF, 71KB)
    Spanish (PDF, 54KB)
    English (PDF, 237KB)
    Spanish (PDF, 275KB)
    PPO Savings Plus 2250 English (PDF, 71KB)
    Spanish (PDF, 55KB)
    English (PDF, 251KB)
    Spanish (PDF, 287KB)
    PPO Savings Plus 2600 Individual/5200 Family* English (PDF, 71KB)
    Spanish (PDF, 56KB)
    English (PDF, 237KB)
    Spanish (PDF, 275KB)
    Shield Spectrum PPO Savings Plus 2400/4800 - Foundation* English (PDF, 70KB)
    Spanish (PDF, 54KB)
    English (PDF, 130KB)
    Spanish (PDF, 130KB)
    Optional Benefits

    For PPO Savings Plus 2250

    Substance Abuse
    English (PDF, 23KB)
    Spanish (PDF, 36KB)

    Infertility
    English (PDF, 29KB)
    Spanish (PDF, 29KB)

    For PPO Savings Plus 1500**, PPO Savings Plus 2400 Individual/4800 Family, Shield Spectrum PPO Savings Plus 2400 Individual/4800 Family Foundation**, and PPO Savings Plus 2600 Individual 5200/Family

    Substance Abuse
    English (PDF, 23KB)
    Spanish (PDF, 29KB)

    Infertility
    English (PDF, 32KB)
    Spanish (PDF, 97KB)

     

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    Active ChoiceSM Plans*
    Plan Name Benefit Summaries Prescription Drug Coverage
    Active Choice Plan 500 English (PDF, 59KB)
    Spanish (PDF, 63KB)
    Drug Coverage Options
    Active Choice Plan 750 English (PDF, 59KB)
    Spanish (PDF, 64KB)
    Drug Coverage Options
    Active Choice 750 - Foundation* English (PDF, 59KB)
    Spanish (PDF, 64KB)
    Drug Coverage Options
    Optional Benefits

    For Active Choice 500

    Substance Abuse
    English (PDF, 23KB)
    Spanish (PDF, 28KB)

    Infertility
    English (PDF, 32KB)
    Spanish (PDF, 97KB)

    For Active Choice 750

    Substance Abuse
    English (PDF, 23KB)
    Spanish (PDF, 30KB)

    Infertility
    English (PDF, 32KB)
    Spanish (PDF, 97KB)

     

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    Access Baja® Plans
    Plan Name Benefit Summaries Disclosures
    Access Baja Plan 5 English (PDF, 62KB)
    Spanish (PDF, 62KB)
    English (PDF, 252KB)
    Spanish (PDF, 250KB)
    Access Baja Plan 10 English (PDF, 62KB)
    Spanish (PDF, 62KB)
    English (PDF, 252KB)
    Spanish (PDF, 250KB)

     

    Closed Plans - Available to existing renewing groups only
    Plan Name Benefit Summaries Prescription Drug Coverage
    HMO 10 - 1000/Admit Inpatient
    (Suggested alternate:
    HMO 10 - 20%/Zero Facility Deductible)
    English (PDF, 36KB)
    Spanish (PDF, 43KB)
    Drug Coverage Options
    HMO 15 - 1000/Admit Inpatient (Suggested alternate:
    HMO 15 - 20%/Zero Facility Deductible)
    English (PDF, 35KB)
    Spanish (PDF, 39KB)
    Drug Coverage Options
    HMO 20 - 1000/Admit Inpatient
    (Suggested alternate:
    HMO 20 - 25%/Zero Facility Deductible)
    English (PDF, 36KB)
    Spanish (PDF, 39KB)
    Drug Coverage Options
    HMO 25 - 1000/Admit Inpatient
    (Suggested alternate:
    HMO 20 - 25%/Zero Facility Deductible)
    English (PDF, 36KB)
    Spanish (PDF, 39KB)
    Drug Coverage Options
    POS 500 - 100/90/70
    (Suggested alternate:
    Any current POS plan)
    English (PDF, 62KB)
    Spanish (PDF, 46KB)
    Drug Coverage Options
    PPO 1000 - 80/50
    (Suggested alternate:
    PPO 1000 - 80/60 Premier)
    English (PDF, 63KB)
    Spanish (PDF, 46KB)
    Drug Coverage Options
    PPO 1000 80/60
    (Suggested alternate:
    PPO 1000 - 80/60 Premier)
    English (PDF, 63KB)
    Spanish (PDF, 45KB)
    Drug Coverage Options
    PPO 1500 - 80/60
    (Suggested alternate:
    PPO 1000 - 80/60 Premier)
    English (PDF, 63KB)
    Spanish (PDF, 45KB)
    Drug Coverage Options
    PPO 1500 - 90/70
    (Suggested alternate:
    PPO 1000 - 80/60 Premier)
    English (PDF, 62KB)
    Spanish (PDF, 45KB)
    Drug Coverage Options
    PPO 3000 - 80/50*
    (Suggested alternate:
    PPO 1000 - 80/60 Premier)
    English (PDF, 62KB)
    Spanish (PDF, 46KB)
    Drug Coverage Options

     

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    * Underwritten by Blue Shield of California Life and Health Insurance Company.

    ** Pending regulatory approval.

    TS Owner:sinta01 Updated:Wed Jan 25 02:58:48 2012 Page:Edit
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