Summary of Benefits 2023

 

For 2023 medical plans, the Summary of Benefits (SOBs) include coverage information in a simplified format, making it easier for members to read and understand their plan benefits. SOBs are included in renewals, open enrollment materials and member welcome kits as part of the Evidence of Coverage (EOC).

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

In addition to the SOBs, the Summary of Benefits and Coverage (SBC) Forms provide your clients with an easy-to-understand overview of what our plans for groups of 1 to 100 cover. Download SBC forms and other resources.

These SOBs are effective January 1, 2023, for small businesses of 1 to 100.

Off-exchange package for Small Business — HMO plans

Blue Shield Off-Exchange HMO Plans Summary of Benefits Disclosures Optional Benefit
Platinum Access+ HMO® 0/20 OffEx English (PDF, 1 MB)
Spanish (PDF, 1.8 MB)
English (PDF, 1.1 MB)
 
Infertility
English (PDF, 997 KB) 
Spanish (PDF, 1.7 MB)
Platinum Local Access+ HMO® 0/20 OffEx English (PDF, 1 MB)
Spanish (PDF, 1.8 MB)
English (PDF, 1.1 MB) Infertility
English (PDF, 997 KB) 
Spanish (PDF, 1.7 MB)
Platinum Trio HMO 0/20 OffEx English (PDF, 1 MB)
Spanish (PDF, 1.8 MB)
English (PDF, 1.1 MB) Infertility
English (PDF, 997 KB) 
Spanish (PDF, 1.7 MB)
Platinum Access+ HMO® 0/25 OffEx English (PDF, 1 MB)
Spanish (PDF, 1.8 MB)
English (PDF, 1.1 MB) Infertility
English (PDF, 997 KB) 
Spanish (PDF, 1.7 MB)
Platinum Local Access+ HMO® 0/25 OffEx English (PDF, 1 MB)
Spanish (PDF, 1.8 MB)

English (PDF, 1.1 MB)
Infertility
English (PDF, 997 KB) 
Spanish (PDF, 1.7 MB)
Platinum Trio HMO 0/25 OffEx English (PDF, 1 MB)
Spanish (PDF, 1.8 MB)

English (PDF, 1.1 MB)
Infertility
English (PDF, 997 KB) 
Spanish (PDF, 1.7 MB)
Platinum Access+ HMO® 0/30 OffEx English (PDF, 1 MB)
Spanish (PDF, 1.8 MB)

English (PDF, 1.1 MB)
Infertility
English (PDF, 997 KB) 
Spanish (PDF, 1.7 MB)
Platinum Local Access+ HMO® 0/30 OffEx English (PDF, 1MB)
Spanish (PDF, 1.8MB)

English (PDF, 1.1 MB)
Infertility
English (PDF, 997 KB) 
Spanish (PDF, 1.7 MB)
Platinum Trio HMO 0/30 OffEx English (PDF, 1 MB)
Spanish (PDF, 1.8 MB)

English (PDF, 1.1 MB)
Infertility
English (PDF, 997 KB) 
Spanish (PDF, 1.7 MB)
Gold Access+ HMO® 0/30 OffEx English (PDF, 1 MB)
Spanish (PDF, 1.8 MB)

English (PDF, 1.1 MB)
Infertility
English (PDF, 997 KB) 
Spanish (PDF, 1.7 MB)
Gold Local Access+ HMO® 0/30 OffEx English (PDF, 1 MB)
Spanish (PDF, 1.8 MB)
English (PDF, 1.1 MB) Infertility
English (PDF, 997 KB) 
Spanish (PDF, 1.7 MB)
Gold Trio HMO 0/30 OffEx English (PDF, 1 MB)
Spanish (PDF, 1.8 MB)

English (PDF, 1.1 MB)
Infertility
English (PDF, 997 KB) 
Spanish (PDF, 1.7 MB)
Gold Access+ HMO® 500/35 OffEx English (PDF, 1 MB)
Spanish (PDF, 1.8 MB)

English (PDF, 1.1 MB)
Infertility
English (PDF, 997 KB) 
Spanish (PDF, 1.7 MB)
Gold Local Access+ HMO® 500/35 OffEx English (PDF, 1 MB)
Spanish (PDF, 1.8 MB)

English (PDF, 1.1 MB)
Infertility
English (PDF, 997 KB) 
Spanish (PDF, 1.7 MB)
Gold Trio HMO 500/35 OffEx English (PDF, iMB)
Spanish (PDF, 1.8MB)

English (PDF, 1.1 MB)
Infertility
English (PDF, 996.9KB) 
Spanish (PDF, 1.7MB)
Gold Access+ HMO® 1000/35 OffEx English (PDF, 1 MB) 
Spanish (PDF, 1.8 MB)

English (PDF, 1.1 MB)
Infertility
English (PDF, 997 KB) 
Spanish (PDF, 1.7 MB)
Gold Local Access+ HMO® 1000/35 OffEx English (PDF, 1 MB) 
Spanish (PDF, 1.8 MB)

English (PDF, 1.1 MB)
Infertility
English (PDF, 997 KB) 
Spanish (PDF, 1.7 MB)
Gold Trio HMO 1000/35 OffEx English (PDF, 1 MB) 
Spanish (PDF, 1.8 MB)

English (PDF, 1.1 MB)
Infertility
English (PDF, 997 KB) 
Spanish (PDF, 1.7 MB)
Gold Access+ HMO® 1500/35 OffEx English (PDF, 1 MB) 
Spanish (PDF, 1.8 MB)

English (PDF, 1.1 MB)
Infertility
English (PDF, 997 KB) 
Spanish (PDF, 1.7 MB)
Gold Local Access+ HMO® 1500/35 OffEx English (PDF, 1 MB)
Spanish (PDF, 1.8 MB)

English (PDF, 1.1 MB)
Infertility
English (PDF, 997 KB) 
Spanish (PDF, 1.7 MB)
Gold Trio HMO 1500/35 OffEx English (PDF, 49 KB)
Spanish (PDF, 49 KB)

English (PDF, 1.1 MB)
Infertility
English (PDF, 997 KB) 
Spanish (PDF, 1.7 MB)
Silver Access+ HMO® 2300/70 OffEx English (PDF, 1 MB)
Spanish (PDF, 1.8 MB)

English (PDF, 1.1 MB)
Infertility
English (PDF, 997 KB) 
Spanish (PDF, 1.7 MB)
Silver Access+ HMO® 2750/70 OffEx English (PDF, 1 MB)
Spanish (PDF, 1.8 MB)

English (PDF, 1.1 MB)
Infertility
English (PDF, 997 KB) 
Spanish (PDF, 1.7 MB)
Silver Local Access+ HMO® 2300/70 OffEx English (PDF, 1 MB)
Spanish (PDF, 1.8 MB)

English (PDF, 1.1 MB)
Infertility
English (PDF, 997 KB) 
Spanish (PDF, 1.7 MB)
Silver Local Access+ HMO® 2750/70 OffEx English (PDF, 1 MB)
Spanish (PDF, 1.8 MB)

English (PDF, 1.1 MB)
Infertility
English (PDF, 997 KB) 
Spanish (PDF, 1.7 MB)
Silver Trio HMO 2300/70 OffEx English (PDF, 1 MB)
Spanish (PDF, 1.8 MB)

English (PDF, 1.1 MB)
Infertility
English (PDF, 997 KB) 
Spanish (PDF, 1.7 MB)
Silver Trio HMO 2750/70 OffEx English (PDF, 1 MB)
Spanish (PDF, 1.8 MB)
English (PDF, 1.1 MB) Infertility
English (PDF, 997 KB) 
Spanish (PDF, 1.7 MB)
Bronze Access+ HMO® 7000/70 OffEx English (PDF, 1 MB)
Spanish (PDF, 1.8 MB)

English (PDF, 1.1 MB)
Infertility
English (PDF, 997 KB) 
Spanish (PDF, 1.7 MB)
Bronze Local Access+ HMO 7000/70 OffEx English (PDF, 1 MB)
Spanish (PDF, 1.8MB)

English (PDF, 1.1 MB)
Infertility
English (PDF, 997 KB) 
Spanish (PDF, 1.7 MB)
Bronze Trio HMO 7000/70 OffEx English (PDF, 1 MB)
Spanish (PDF, 1.8 MB)

English (PDF, 1.1 MB)
Infertility
English (PDF, 997 KB) 
Spanish (PDF, 1.7 MB)

Mirror Package for Small Business — HMO plans

Blue Shield Mirror HMO Plans Summary of Benefits Disclosures  Optional Benefit
Blue Shield Trio Platinum 90 HMO 0/20
+ Child Dental 
English (PDF, 1 MB)
Spanish (PDF, 1.8 MB)
English (PDF, 1.1 MB)
 
Infertility
English (PDF, 1.0 MB) 
Spanish (PDF, 1.7 MB)
Blue Shield Trio Gold 80 HMO 250/35
+ Child Dental 
English (PDF, 1 MB) 
Spanish (PDF, 1.8 MB)

English (PDF, 1.1 MB)
Infertility
English (PDF, 1.0 MB) 
Spanish (PDF, 1.7 MB)
Blue Shield Trio Silver 70 HMO 2500/55
+ Child Dental
English (PDF, 1 MB)
Spanish (PDF, 1.8 MB)

English (PDF, 1.1 MB)
Infertility
English (PDF, 1.0 MB) 
Spanish (PDF, 1.7 MB)
Blue Shield Access+ Gold 80 HMO® 250/35 + Child Dental English (PDF, 227 KB)
Spanish (PDF, 276 KB)
English (PDF, 1.1 MB) Infertility
English (PDF, 1.0 MB) 
Spanish (PDF, 1.7 MB)
Blue Shield Access+ Platinum 90 HMO® 0/20 + Child Dental English (PDF, 218 KB)
Spanish (PDF, 263 KB)
English (PDF, 1.1 MB) Infertility
English (PDF, 1.0 MB) 
Spanish (PDF, 1.7 MB)
Blue Shield Access+ Silver 70 HMO® 2500/55 + Child Dental English (PDF, 220 KB)
Spanish (PDF, 267 KB)
English (PDF, 1.1 MB) Infertility
English (PDF, 1.0 MB) 
Spanish (PDF, 1.7 MB)
Blue Shield Bronze Trio 7000/70 + Child Dental English (PDF, 231 KB)
Spanish (PDF, 271 KB)
English (PDF, 1.1 MB) Infertility
English (PDF, 1.0 MB) 
Spanish (PDF, 1.7 MB)

Off-Exchange Package for Small Business – PPO plans

Blue Shield Off-Exchange PPO Plans Summary of Benefits Disclosures Optional Benefit
Platinum Full PPO 0/0 OffEx English (PDF, 1.1 MB)
Spanish (PDF, 1.8 MB)
English (PDF, 1.1 MB)  Infertility
English (PDF, 996.7 KB) 
Spanish (PDF, 1.7 MB)
Platinum Tandem PPO 0/0 OffEx English (PDF, 1.1 MB)
Spanish (PDF, 1.8 MB)
English (PDF, 1.1 MB)  
 
Infertility
English (PDF, 996.7 KB) 
Spanish (PDF, 1.7 MB)
Platinum Full PPO 0/10 OffEx English (PDF, 1.1 MB)
Spanish (PDF, 1.8 MB)
English (PDF, 1.1 MB)  Infertility
English (PDF, 996.7 KB) 
Spanish (PDF, 1.7 MB)
Platinum Tandem PPO 0/10 OffEx  English (PDF, 1.1 MB)
Spanish (PDF, 1.8 MB)
English (PDF, 1.1 MB)  Infertility
English (PDF, 996.7 KB) 
Spanish (PDF, 1.7 MB)
Platinum Full PPO 250/10 OffEx English (PDF, 1.1 MB) 
Spanish (PDF, 1.8 MB)
English (PDF, 1.1 MB)  Infertility
English (PDF, 996.7 KB) 
Spanish (PDF, 1.7 MB)
Platinum Tandem PPO 250/10 OffEx  English (PDF, 1.1 MB)
Spanish (PDF, 1.8 MB)
English (PDF, 1.1 MB)  Infertility
English (PDF, 996.7 KB) 
Spanish (PDF, 1.7 MB)
Platinum Full PPO 250/15 OffEx English (PDF, 1.1 MB) 
Spanish (PDF, 1.8 MB)
English (PDF, 1.1 MB)  
 
Infertility
English (PDF, 996.7 KB) 
Spanish (PDF, 1.7 MB)
Platinum Tandem PPO 250/15 OffEx  English (PDF, 1.1 MB)
Spanish (PDF, 1.9 MB)
English (PDF, 1.1 MB)  
 
Infertility
English (PDF, 996.7 KB) 
Spanish (PDF, 1.7 MB)
Gold Full PPO 0/25 OffEx English (PDF, 1.1 MB)
Spanish (PDF, 1.8 MB)
English (PDF, 1.1 MB)  Infertility
English (PDF, 996.7 KB) 
Spanish (PDF, 1.7 MB)
Gold Tandem PPO 0/25 OffEx English (PDF, 1.1 MB)
Spanish (PDF, 1.8 MB)
English (PDF, 1.1 MB)  Infertility
English (PDF, 996.7 KB) 
Spanish (PDF, 1.7 MB)
Gold Full PPO 500/30 OffEx English (PDF, 1.1 MB)
Spanish (PDF, 1.8 MB)
English (PDF, 1.1 MB)  Infertility
English (PDF, 996.7 KB) 
Spanish (PDF, 1.7 MB)
Gold Tandem PPO 500/30 OffEx English (PDF, 1.1 MB)
Spanish (PDF, 1.9 MB)
English (PDF, 1.1 MB)  Infertility
English (PDF, 996.7 KB) 
Spanish (PDF, 1.7 MB)
Gold Full PPO 750/30 OffEx English (PDF, 1.1 MB)
Spanish (PDF, 1.8 MB)
English (PDF, 1.1 MB)  Infertility
English (PDF, 996.7 KB) 
Spanish (PDF, 1.7 MB)
Gold Tandem PPO 750/30 OffEx  English (PDF, 1.1 MB)
Spanish (PDF, 1.9 MB)
English (PDF, 1.1 MB)  Infertility
English (PDF, 996.7 KB) 
Spanish (PDF, 1.7 MB)
Gold Full PPO 1000/35 OffEx English (PDF, 1.1MB)
Spanish (PDF, 1.8MB)
English (PDF, 1.1 MB)  Infertility
English (PDF, 996.7KB) 
Spanish (PDF, 1.7MB)
Gold Tandem PPO 1000/35 OffEx English (PDF, 1.1 MB)
Spanish (PDF, 1.9 MB)
English (PDF, 1.1 MB)  
 
Infertility
English (PDF, 996.7 KB) 
Spanish (PDF, 1.7 MB)
Silver Full PPO 2000/60 OffEx English (PDF, 1.1 MB)
Spanish (PDF, 1.8 MB)
English (PDF, 1.1 MB)  Infertility
English (PDF, 996.7 KB) 
Spanish (PDF, 1.7 MB)
Silver Tandem PPO 2000/60 OffEx  English (PDF, 1.1 MB)
Spanish (PDF, 1.9 MB)
English (PDF, 1.1 MB)  Infertility
English (PDF, 996.7 KB) 
Spanish (PDF, 1.7 MB)
Silver Full PPO 2350/65 OffEx English (PDF, 1.1 MB)
Spanish (PDF, 1.8 MB)
English (PDF, 1.1 MB)  Infertility
English (PDF, 996.7 KB) 
Spanish (PDF, 1.7 MB)
Silver Tandem PPO 2350/65 OffEx  English (PDF, 1.1 MB)
Spanish (PDF, 1.9 MB)
English (PDF, 1.1 MB)  Infertility
English (PDF, 996.7 KB) 
Spanish (PDF, 1.7 MB)
Silver Full PPO 2550/70 OffEx English (PDF, 1.1 MB)
Spanish (PDF, 1.8 MB)  
English (PDF, 1.1 MB)  Infertility
English (PDF, 996.7 KB) 
Spanish (PDF, 1.7 MB)
Silver Tandem PPO 2550/70 OffEx  English (PDF, 1.1 MB)
Spanish (PDF, 1.9 MB)
English (PDF, 1.1 MB)  Infertility
English (PDF, 996.7 KB) 
Spanish (PDF, 1.7 MB)
Bronze Full PPO 5500/65 OffEx English (PDF, 1.1 MB)
Spanish (PDF, 1.9 MB)
English (PDF, 1.1 MB)  Infertility
English (PDF, 996.7 KB) 
Spanish (PDF, 1.7 MB)
Bronze Tandem PPO 5500/65 OffEx English (PDF, 1.1 MB)
Spanish (PDF, 1.9 MB)
English (PDF, 1.1 MB)  Infertility
English (PDF, 996.7 KB) 
Spanish (PDF, 1.7 MB)
Bronze Full PPO 6250/65 OffEx English (PDF, 1.1 MB)
Spanish (PDF, 1.9 MB)
English (PDF, 1.1 MB)  Infertility
English (PDF, 996.7 KB) 
Spanish (PDF, 1.7 MB)
Bronze Tandem PPO 6250/65 OffEx English (PDF, 1.1 MB)
Spanish (PDF, 1.9 MB)
English (PDF, 1.1 MB)  Infertility
English (PDF, 996.7 KB) 
Spanish (PDF, 1.7 MB)
Bronze Full PPO 6500/70 OffEx English (PDF, 1.1 MB)
Spanish (PDF, 1.9 MB)
English (PDF, 1.1 MB)  Infertility 
English (PDF, 996.7KB) 
Spanish (PDF, 1.7 MB)
Bronze Tandem PPO 6500/70 OffEx English (PDF, 1.1 MB)
Spanish (PDF, 1.9 MB)
English (PDF, 1.1 MB)  Infertility
English (PDF, 996.7 KB) 
Spanish (PDF, 1.7 MB)
Bronze Full PPO 7500/65 OffEx English (PDF, 1.1  MB)
Spanish (PDF, 1.9MB)
English (PDF, 1.1 MB)  Infertility
English (PDF, 996.7 KB) 
Spanish (PDF, 1.7 MB)
Bronze Tandem PPO 7500/65 OffEx English (PDF, 1.1 MB)
Spanish (PDF, 1.9 MB)
English (PDF, 1.1 MB)  Infertility
English (PDF, 996.7 KB) 
Spanish (PDF, 1.7 MB)
Bronze Full PPO 6850/55 OffEx English (PDF, 1.1 MB)
Spanish (PDF, 1.9 MB)
English (PDF, 1.1 MB)  IInfertility
English (PDF, 996.7 KB) 
Spanish (PDF, 1.7 MB)
Bronze Tandem PPO 6850/55 OffEx English (PDF, 1.1 MB)
Spanish (PDF, 1.9 MB)
English (PDF, 1.1 MB) 
 
Infertility
English (PDF, 996.7 KB) 
Spanish (PDF, 1.7 MB)

 

Virtual Blue Plans Summary of Benefits Disclosures Optional Benefit
Virtual Blue℠ Gold Tandem PPO 1500/45 OffEx English (PDF, 275 KB)
Spanish (PDF, 344 KB)
English (PDF, 310 KB) 
 
Infertility
English (PDF, 996.7 KB) 
Spanish (PDF, 1.7 MB)
Virtual Blue℠ Bronze Tandem PPO 7500/75 OffEx English (PDF, 288 KB)
Spanish (PDF, 353 KB)
English (PDF, 310 KB) 
 
Infertility
English (PDF, 996.7 KB) 
Spanish (PDF, 1.7 MB)

Mirror Package for Small Business — PPO plans

Blue Shield Mirror PPO Plans Summary of Benefits Disclosures  Optional Benefit
Blue Shield Platinum 90 PPO 0/15
+ Child Dental 
English (PDF, 1.1 MB)
Spanish (PDF, 1.8 MB)
English (PDF, 1.1 MB)
 
Infertility
English (PDF, 1.0 MB)
Spanish (PDF, 1.7 MB)
Blue Shield Gold 80 PPO 350/25
+ Child Dental
English (PDF, 1.1 MB)
Spanish (PDF, 1.8 MB)
English (PDF, 1.1 MB)
 
Infertility
English (PDF, 1.0 MB)
Spanish (PDF, 1.7 MB)
Blue Shield Silver 70 PPO 2500/50
+ Child Dental
English (PDF, 1.1 MB)
Spanish (PDF, 1.8 MB)
English (PDF, 1.1 MB)
 
Infertility
English (PDF, 1.0 MB)
Spanish (PDF, 1.7 MB)
Blue Shield Bronze 60 PPO 6300/65
+ Child Dental
English (PDF, 1.1 MB)
Spanish (PDF, 1.9 MB)
English (PDF, 1.1 MB)
 
Infertility
English (PDF, 1.0 MB)
Spanish (PDF, 1.7 MB)
Blue Shield Bronze Full PPO Savings 7000 + Child Dental English (PDF, 257 KB)
Spanish (PDF, 330 KB)
English (PDF, 340 KB)
 
Infertility
English (PDF, 1.0 MB)
Spanish (PDF, 1.7 MB)
Blue Shield Silver Full PPO Savings 2300/25% + Child Dental English (PDF, 267 KB)
Spanish (PDF, 331 KB)
English (PDF, 340 KB)
 
Infertility
English (PDF, 1.0 MB)
Spanish (PDF, 1.7 MB)

Off-Exchange Package for Small Business — HSA/HDHP

Blue Shield Off-Exchange HSA HDHP Plans Summary of Benefits Disclosures Optional Benefit
Gold Full PPO Savings 1750/15% HDHP PrevRx OffEx English (PDF, 1 MB)
Spanish (PDF, 1.8 MB)
English (PDF, 1.1 MB) 
 
Infertility
English (PDF, 996.6 KB) 
Spanish (PDF, 1.7 MB)
Gold Tandem PPO Savings 1750/15% HDHP PrevRx OffEx English (PDF, 1 MB)
Spanish (PDF, 1.9 MB)
English (PDF, 1.1 MB)  Infertility
English (PDF, 996.6 KB) 
Spanish (PDF, 1.7 MB)
Silver Full PPO Savings 2300/25% OffEx English (PDF, 1 MB)
Spanish (PDF, 1.8 MB)

English (PDF, 1.1 MB) 
Infertility
English (PDF, 996.6 KB) 
Spanish (PDF, 1.7 MB)
Silver Tandem PPO Savings 2300/25% OffEx English (PDF, 1 MB)
Spanish (PDF, 1.8 MB)

English (PDF, 1.1 MB) 
Infertility
English (PDF, 996.6 KB) 
Spanish (PDF, 1.7 MB)
Silver Full PPO Savings 2600/35% HDHP PrevRx OffEx English (PDF, 1 MB)
Spanish (PDF, 1.8 MB)

English (PDF, 1.1 MB) 
Infertility
English (PDF, 996.6 KB) 
Spanish (PDF, 1.7 MB)
Silver Tandem PPO Savings 2600/35% HDHP PrevRx OffEx English (PDF, 1 MB)
Spanish (PDF, 1.9 MB)

English (PDF, 1.1 MB) 
Infertility
English (PDF, 996.6 KB) 
Spanish (PDF, 1.7 MB)
Bronze Full PPO Savings 5700/40% OffEx English (PDF, 1 MB) 
Spanish (PDF, 1.8 MB)

English (PDF, 1.1 MB) 
Infertility
English (PDF, 996.6 KB) 
Spanish (PDF, 1.7 MB)
Bronze Tandem PPO Savings 5700/40% OffEx English (PDF, 1MB) 
Spanish (PDF, 1.9MB)
English (PDF, 1.1 MB)  Infertility
English (PDF, 996.6 KB) 
Spanish (PDF, 1.7 MB)
Bronze Full PPO Savings 7000 OffEx English (PDF, 1 MB)
Spanish (PDF, 1.8 MB)

English (PDF, 1.1 MB) 
Infertility
English (PDF, 996.6 KB) 
Spanish (PDF, 1.7 MB)
Bronze Tandem PPO Savings 7000 OffEx English (PDF, 1 MB)
Spanish (PDF, 1.8 MB)

English (PDF, 1.1 MB) 
Infertility
English (PDF, 996.6 KB) 
Spanish (PDF, 1.7 MB)

© 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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