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July 2008 Benefit Summaries
Uniform Health Plan Benefits and Coverage Matrices
The following benefit summaries are effective July 1, 2008 and thereafter unless otherwise noted. All benefit summaries are for groups of 2 to 50.
 
Please contact your Blue Shield representative to learn about additional optional benefits that are available. 
 
Access+ HMO Plans
 Plan Name  Benefit Summaries 
 HMO Plan 5 English
Spanish
 
 
 HMO Plan 10 English
Spanish
 
 
 HMO Plan 15 English
Spanish
 
 
 HMO Plan 20 English
Spanish
 
 
 HMO Plan 20 Value English
Spanish
 
 
 HMO Plan 25 English
Spanish
 
 
 HMO Plan 30 English
Spanish
 
 
 HMO Plan 40 English
Spanish
 
 
Access+HMO Plan Disclosure Forms  
 With 2-Tier Closed Formulary Prescription
 Drug Coverage
 
 English
 Spanish
With 3-Tier Closed Formulary Prescription
Drug Coverage
 
English
Spanish
 Optional Benefits
 Optional Benefits for all Access+ HMO Plans
 Substance Abuse
 English
 Spanish
 
 Chiropractic
 English
 Spanish
Chiropractic & Acupuncture
English
Spanish
 
Infertility
English
Spanish
 
Added Advantage POS Plans
 Plan Name  Benefit Summaries 
 POS Plan
 
 English
 Spanish
 
Added Advantage POS Plan Disclosure Forms  
 With 2-Tier Closed Formulary Prescription
 Drug Coverage
 
 English
 Spanish
With 3-Tier Closed Formulary Prescription
Drug Coverage
 
English
Spanish
 Optional Benefits
 Optional Benefits for all POS Plans
 Substance Abuse
 English
 Spanish
 
 
 Chiropractic
 English
 Spanish
 Chiropractic & Acupuncture
 English
 Spanish

 
 Infertility
 English
 Spanish
Shield Spectrum PPO Plans
 Plan Name Benefit Summaries  Disclosures 
 PPO Plan, Zero Deductible English
Spanish
 English
 Spanish
 PPO Plan 250 Premier English
Spanish
 English
 Spanish
 PPO Plan 250 Standard English
Spanish
 English
 Spanish
 PPO Plan 500 Premier English
Spanish
 English
 Spanish
 PPO Plan 500 Standard* English
Spanish
 English
 Spanish
 PPO Plan 500 Value* English
Spanish
 English
 Spanish
 PPO Plan 750 Value* English
Spanish
 English
 Spanish
 PPO Plan 1000 English
Spanish
 English
 Spanish
 PPO Plan 1000 Value* English
Spanish
 English
 Spanish
 PPO Plan 1500 Value* English
Spanish
 English
 Spanish
 PPO Plan 3000* English
Spanish
 English
 Spanish
 Optional Benefits
For PPO Plan, Zero Deductible, Plan 250 Premier, Plan 250 Standard, Plan 500 Premier, and Plan 1000
 
 
 Substance Abuse
 English
 Spanish
 
 
 Infertility
 English
 Spanish
 
For PPO Plan 500 Standard, Plan 500 Value, Plan 750 Value, Plan 1000 Value, Plan 1500 Value and Plan 3000
 
 
Substance Abuse
English
Spanish
 
 
Infertility
English
Spanish
Shield Spectrum PPO Savings Plan
Plan Name Benefit Summaries  Disclosures 
 PPO Savings Plan 1800/3600*
 
English
Spanish
 English
 Spanish
 PPO Savings Plan 2250/4500 English
Spanish
 English
 Spanish
 PPO Savings Plan 2500* English
Spanish
 English
 Spanish
 PPO Savings Plan 3000/6000*
 
English
Spanish
 English
 Spanish
 PPO Savings Plan 4800* English
Spanish
 English
 Spanish
 Optional Benefits
 For PPO Savings Plan 2250/4500
 
 
 Substance Abuse
 English
 Spanish
 
 
 Infertility
 English
 Spanish
 
For PPO Savings Plan 1800/3600, 2500, PPO Savings Plan 3000/6000, PPO Savings Plan 4800
 
Substance Abuse
English
Spanish
 
 
Infertility
English
Spanish

Active Choice Plans
 Plan Name  Benefit Summaries
 Active Choice 500*  English
 Spanish
 
 
 Active Choice 750*  English
 Spanish
 
 
 Active Choice Plan Disclosure Forms
 English 
 Spanish
 Optional Benefits
 For Active Choice Plan 500
 
 Substance Abuse
 English
 Spanish
 

 Infertility
 English
 Spanish
 
 For Active Choice Plan 750
 
 Substance Abuse
 English
 Spanish
 
 
 Infertility
 English
 Spanish
 
Access Baja HMO Plans
 Plan Name  Benefit Summaries
 Access Baja Plan 5  English
 Spanish
 
 Access Baja Plan 10  English
 Spanish
 
 Access Baja HMO Plan Disclosure Forms
 
 
 English
 Spanish
 Dependent Only
 
 English  
 Spanish
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