Summary of Benefits 2022

Large Groups (101 and above)

The Summary of Benefits (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).

See FAQs about the new Summary of Benefits.

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 (PDF, 1.1 MB)
 

Access+ HMO® Zero Admit 15
English (PDF, 952 KB)
Spanish (PDF, 139 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 (PDF, 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)
Addinal 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, 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 (PDF, 1.1 MB)

Access+ HMO® Per Admit 10-250 English (PDF, 1 MB)
Spanish (PDF, 162 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 (PDF, 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 (PDF, 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 (PDF, 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 (PDF, 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 (PDF, 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 (PDF, 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 (PDF, 1.1 MB)

Access+ HMO® Facility Coinsurance
15-20%
English (PDF, 1 MB)
Spanish (PDF, 162 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 (PDF, 1.1 MB)

Access+ HMO® Facility Coinsurance
20-20%
English (PDF, 1 MB)
Spanish (PDF, 162 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 (PDF, 1.1 MB)

Access+ HMO® Facility Coinsurance
25-25%
English (PDF, 1 MB)
Spanish (PDF, 1 MB)

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 (PDF, 1.1 MB)

Access+ HMO® Facility Coinsurance 30-30%

English (PDF, 1 MB)
Spanish (PDF, 162 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 (PDF, 1.1 MB)

Access+ HMO® Facility Coinsurance
40-40%
English (PDF, 1 MB)
Spanish (PDF, 162 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 (PDF, 1.1 MB)

Access+ HMO® Zero Facility Deductible
30-20%
English  (PDF, 1 MB)
Spanish (PDF, 162 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 (PDF, 1.1 MB)

Access+ HMO® Facility Deductible 15-10%/250 English (PDF, 1 MB)
Spanish (PDF, 165 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 (PDF, 1.1 MB)

Access+ HMO® Facility Deductible 15-10%/500 English  (PDF, 1 MB)
Spanish (PDF, 165 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 (PDF, 1.1 MB)

Access+ HMO® Facility Deductible 15-10%/750 English (PDF, 1 MB)
Spanish (PDF, 165 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 (PDF, 1.1 MB)

Access+ HMO® Facility Deductible
15-10%/1500
English (PDF, 1 MB)
Spanish (PDF, 165 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 (PDF, 1.1 MB)

Access+ HMO® Facility Deductible
20-25%/1500
English (PDF, 1 MB)
Spanish (PDF, 162 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 (PDF, 1.1 MB)

Access+ HMO® Facility Deductible
30-10%/1500
English (PDF, 1 MB)
Spanish (PDF, 165 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 (PDF, 1.1 MB)

Access+ HMO® Facility Deductible 30-30%/2000 English (PDF, 1 MB)
Spanish (PDF, 165 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 (PDF, 1.1 MB)

Access+ HMO® Facility Deductible 40-40%/2000 English (PDF, 1 MB)
Spanish (PDF, 165 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 (PDF, 1.1 MB)

Access+ HMO® Facility Deductible 40-40%/5800 English (PDF, 1 MB)
Spanish (PDF, 165 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 (PDF, 1.1 MB)

Access+ HMO SaveNet plans Summary of Benefits Optional benefits Disclosures
Access+ HMO® SaveNet
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 (PDF, 1.1 MB)
Access+ HMO® SaveNet
Zero Admit 20
English (PDF, 1 MB)
Spanish (PDF, 165 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 (PDF, 1.1 MB)
Access+ HMO® SaveNet
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 (PDF, 1.1 MB)
Access+ HMO® SaveNet
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 (PDF, 1.1 MB)
Access+ HMO® SaveNet
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 (PDF, 1.1 MB)
Access+ HMO® SaveNet
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 (PDF, 1.1 MB)
Access+ HMO® SaveNet
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 (PDF, 1.1 MB)
Access+ HMO® SaveNet
Facility Coinsurance 15-20%
English (PDF, 1 MB)
Spanish (PDF, 162 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 (PDF, 1.1 MB)
Access+ HMO® SaveNet
Facility Coinsurance 20-20%
English (PDF, 1 MB)
Spanish (PDF, 162 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 (PDF, 1.1 MB)
Access+ HMO® SaveNet
Facility Coinsurance 25-25%
English (PDF, 1 MB)
Spanish (PDF, 162 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 (PDF, 1.1 MB)
Access+ HMO® SaveNet
Facility Coinsurance 40-40%
English (PDF, 1 MB)
Spanish (PDF, 162 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 (PDF, 1.1 MB)
Access+ HMO® SaveNet 
Facility Deductible
15-10%/1500
English (PDF, 1 MB)
Spanish (PDF, 162 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 (PDF, 1.1 MB)
Access+ HMO® SaveNet
Facility Deductible
20-25%/1500
English (PDF, 1 MB)
Spanish (PDF, 165 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 (PDF, 1.1 MB)
Access+ HMO® SaveNet
Facility Deductible
30-30%/2000
English (PDF, 1 MB)
Spanish (PDF, 165 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 (PDF, 1.1 MB)
Access+ HMO® SaveNet
Facility Deductible
40-40%/2000
English (PDF, 1 MB)
Spanish (PDF, 166 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 (PDF, 1.1 MB)
Access+ HMO® SaveNet
Facility Deductible
40-40%/5800
English (PDF, 1 MB)
Spanish (PDF, 152 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 (PDF, 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 (PDF, 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 (PDF, 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 (PDF, 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 (PDF, 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 (PDF, 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 (PDF, 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 (PDF, 1.1 MB)

Local Access+ HMO® Facility Coinsurance 15-20% English  (PDF, 1 MB)
Spanish  (PDF, 162 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 (PDF, 1.1 MB)

Local Access+ HMO® Facility Coinsurance 20-20% English  (PDF, 1 MB)
Spanish  (PDF, 162 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 (PDF, 1.1 MB)

Local Access+ HMO® Facility Coinsurance 25-25%

English (PDF, 1 MB)
Spanish (PDF, 162 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 (PDF, 1.1 MB)

Local Access+ HMO® Facility Coinsurance 40-40% English  (PDF, 1 MB)
Spanish  (PDF, 162 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 (PDF, 1.1 MB)

Local Access+ HMO® Facility Deductible 15-10%/1500 English  (PDF, 1 MB)
Spanish (PDF, 165 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 (PDF, 1.1 MB)

Local Access+ HMO® Facility Deductible 20-25%/1500 English  (PDF, 1 MB)
Spanish  (PDF, 165 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 (PDF, 1.1 MB)

Local Access+ HMO® Facility Deductible 30-30%/2000 English  (PDF, 1 MB)
Spanish  (PDF, 165 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 (PDF, 1.1 MB)

Local Access+ HMO® Facility Deductible 40-40%/2000 English  (PDF, 1 MB)
Spanish (PDF, 165 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 (PDF, 1.1 MB)

Local Access+ HMO® Facility Deductible 40-40%/5800 English  (PDF, 1 MB)
Spanish  (PDF, 166 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 (PDF, 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 (PDF, 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 (PDF, 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 (PDF, 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 (PDF, 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 (PDF, 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 (PDF, 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 (PDF, 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 (PDF, 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 (PDF, 1.1 MB)

Trio HMO Per Day 15-500 English (PDF, 1 MB)
Spanish (PDF, 160 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 (PDF, 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 (PDF, 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 (PDF, 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 (PDF, 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 (PDF, 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 (PDF, 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 (PDF, 1.1 MB)

Trio HMO Facility Deductible 15-10%/250 English (PDF, 1 MB)
Spanish (PDF, 165 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 (PDF, 1.1 MB)

Trio HMO Facility Deductible 15-10%/500

 

English (PDF, 1 MB)
Spanish (PDF, 165 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 (PDF, 1.1 MB)

Trio HMO Facility Deductible 15-10%/750 English (PDF, 1 MB)
Spanish (PDF, 165 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 (PDF, 1.1 MB)

Trio HMO Facility Deductible 15-10%/1500 English (PDF, 1 MB)
Spanish (PDF, 165 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 (PDF, 1.1 MB)

Trio HMO Facility Deductible 20-25%/1500 English  (PDF, 1 MB)
Spanish  (PDF, 165 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 (PDF, 1.1 MB)

Trio HMO Facility Deductible 30-10%/1500 English (PDF, 1 MB)
Spanish (PDF, 165 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 (PDF, 1.1 MB)

Trio HMO Facility Deductible 30-30%/2000 English  (PDF, 1 MB)
Spanish  (PDF, 165 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 (PDF, 1.1 MB)

Trio HMO Facility Deductible 40-40%/2000 English (PDF, 1 MB)
Spanish (PDF, 165 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 (PDF, 1.1 MB)

Trio HMO Facility Deductible 40-40%/5800 English  (PDF, 1 MB)
Spanish (PDF, 166 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 (PDF, 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 (PDF, 1.1 MB)

Full PPO plans Summary of Benefits Optional benefits  Disclosures
Full 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, 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 No Network Deductible 20 100/50 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, 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 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, 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 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, 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 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, 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 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 Combined Deductible 10-500 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 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, 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 20-200 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 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, 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 25-250 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, 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 25-250 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 Combined Deductible 30-500 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 Combined Deductible 30-750 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 Combined Deductible 35-500 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 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 Combined Deductible Value 50-4500 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, 47 KB)
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 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 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 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 Savings Two-Tier plans Summary of Benefits Optional benefits  Disclosures
Full PPO Savings Two-Tier
Embedded Deductible 1400/2800/2800
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 1500/2800/3000
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 1500/2800/3000 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 1500/2800/3000
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 1800/2800/3600
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 2250/2800/4500
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 2250/2800/4500
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 plans Summary of Benefits Optional benefits Disclosures
Full PPO Savings Embedded Deductible 2800 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 Embedded Deductible 3000 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 Embedded Deductible 3000 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 Embedded Deductible 3500 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 Embedded Deductible 4000

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 Embedded Deductible 4400 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 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)
Full 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)
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
20-200 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 Combined Deductible
25-250 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 25-250 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)
Tandem 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, 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 30-1500 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, 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 Split Deductible 40-3000 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, 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 3000 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 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® 500 80/50 English (PDF, 882 KB)
Spanish (PDF, 916 KB)

English
Hearing aid (PDF, 974 KB)
Base infertility 50% (PDF, 727 KB)
Additional infertility 50% (PDF, 727 KB)
Additional infertility 80% (PDF, 728 KB)
Additional infertility 95% (PDF, 728 KB)

Spanish
Hearing aid (PDF, 758 KB)
Base infertility 50% (PDF, 772 KB)
Additional infertility 50% (PDF, 771 KB)
Additional infertility 80% (PDF, 772 KB)
Additional infertility 95% (PDF, 772 KB)

English (PDF, 1.3 MB)
Active Choice® 500 80/50 
1500 Deductible
English (PDF, 882 KB)
Spanish (PDF, 994 KB)

English
Hearing aid (PDF, 974 KB)
Base infertility 50% (PDF, 727 KB)
Additional infertility 50% (PDF, 727 KB)
Additional infertility 80% (PDF, 728 KB)
Additional infertility 95% (PDF, 728 KB)

Spanish
Hearing aid (PDF, 758 KB)
Base infertility 50% (PDF, 772 KB)
Additional infertility 50% (PDF, 771 KB)
Additional infertility 80% (PDF, 772 KB)
Additional infertility 95% (PDF, 772 KB)

English (PDF, 1.3 MB)
Active Choice® 750 70/50 English (PDF, 882 KB)
Spanish (PDF, 994 KB)

English
Hearing aid (PDF, 974 KB)
Base infertility 50% (PDF, 727 KB)
Additional infertility 50% (PDF, 727 KB)
Additional infertility 80% (PDF, 728 KB)
Additional infertility 95% (PDF, 728 KB)

Spanish
Hearing aid (PDF, 758 KB)
Base infertility 50% (PDF, 772 KB)
Additional infertility 50% (PDF, 771 KB)
Additional infertility 80% (PDF, 772 KB)
Additional infertility 95% (PDF, 772 KB)

English (PDF, 1.3 MB)
Active Choice® 750 70/50 1000 Deductible English (PDF, 882 KB)
Spanish (PDF, 919 KB)

English
Hearing aid (PDF, 974 KB)
Base infertility 50% (PDF, 727 KB)
Additional infertility 50% (PDF, 727 KB)
Additional infertility 80% (PDF, 728 KB)
Additional infertility 95% (PDF, 728 KB)

Spanish
Hearing aid (PDF, 758 KB)
Base infertility 50% (PDF, 772 KB)
Additional infertility 50% (PDF, 771 KB)
Additional infertility 80% (PDF, 772 KB)
Additional infertility 95% (PDF, 772 KB)

English (PDF, 1.3 MB)
Active Choice® 750 80/60 English (PDF, 882 KB)
Spanish (PDF, 984 KB)

English
Hearing aid (PDF, 974 KB)
Base infertility 50% (PDF, 727 KB)
Additional infertility 50% (PDF, 727 KB)
Additional infertility 80% (PDF, 728 KB)
Additional infertility 95% (PDF, 728 KB)

Spanish
Hearing aid (PDF, 758 KB)
Base infertility 50% (PDF, 772 KB)
Additional infertility 50% (PDF, 771 KB)
Additional infertility 80% (PDF, 772 KB)
Additional infertility 95% (PDF, 772 KB)

English (PDF, 1.3 MB)
Active Choice PPO Classic/Plus plans Summary of Benefits Optional benefits  Disclosures
Active Choice® Plus 300 20 80/60 English (PDF, 882 KB)
Spanish (PDF, 916 KB)

English
Hearing aid (PDF, 9724 KB)
Base infertility 50% (PDF, 727 KB)
Additional infertility 50% (PDF, 727 KB)
Additional infertility 80% (PDF, 728 KB)
Additional infertility 95% (PDF, 728 KB)

Spanish
Hearing aid (PDF, 758 KB)
Base infertility 50% (PDF, 772 KB)
Additional infertility 50% (PDF, 771 KB)
Additional infertility 80% (PDF, 772 KB)
Additional infertility 95% (PDF, 772 KB)

English (PDF, 1.1 MB)
Active Choice® Plus 300 80/60 English (PDF, 882 KB)
Spanish (PDF, 994 KB)

English
Hearing aid (PDF, 974 KB)
Base infertility 50% (PDF, 727 KB)
Additional infertility 50% (PDF, 727 KB)
Additional infertility 80% (PDF, 728 KB)
Additional infertility 95% (PDF, 728 KB)

Spanish
Hearing aid (PDF, 758 KB)
Base infertility 50% (PDF, 772 KB)
Additional infertility 50% (PDF, 771 KB)
Additional infertility 80% (PDF, 772 KB)
Additional infertility 95% (PDF, 772 KB)

English (PDF, 1.1 MB)
Active Choice® Plus 1000 20 80/60 English (PDF, 882 KB)
Spanish (PDF, 994 KB)

English
Hearing aid (PDF, 974 KB)
Base infertility 50% (PDF, 727 KB)
Additional infertility 50% (PDF, 727 KB)
Additional infertility 80% (PDF, 728 KB)
Additional infertility 95% (PDF, 728 KB)

Spanish
Hearing aid (PDF, 758 KB)
Base infertility 50% (PDF, 772 KB)
Additional infertility 50% (PDF, 771 KB)
Additional infertility 80% (PDF, 772 KB)
Additional infertility 95% (PDF, 772 KB)

English (PDF, 1.1 MB)
Active Choice® Plus 1000 80/60 English (PDF, 882 KB)
Spanish (PDF, 919 KB)

English
Hearing aid (PDF, 974 KB)
Base infertility 50% (PDF, 727 KB)
Additional infertility 50% (PDF, 727 KB)
Additional infertility 80% (PDF, 728 KB)
Additional infertility 95% (PDF, 728 KB)

Spanish
Hearing aid (PDF, 758 KB)
Base infertility 50% (PDF, 772 KB)
Additional infertility 50% (PDF, 771 KB)
Additional infertility 80% (PDF, 772 KB)
Additional infertility 95% (PDF, 772 KB)

English (PDF, 1.1 MB)
Active Choice® Classic 600 80/50 English (PDF, 882 KB)
Spanish (PDF, 984 KB)

English
Hearing aid (PDF, 974 KB)
Base infertility 50% (PDF, 727 KB)
Additional infertility 50% (PDF, 727 KB)
Additional infertility 80% (PDF, 728 KB)
Additional infertility 95% (PDF, 728 KB)

Spanish
Hearing aid (PDF, 758 KB)
Base infertility 50% (PDF, 772 KB)
Additional infertility 50% (PDF, 771 KB)
Additional infertility 80% (PDF, 772 KB)
Additional infertility 95% (PDF, 772 KB)

English (PDF, 1.1 MB)
Active Choice® Classic 850 70/50 1000 Deductible English (PDF, 882 KB)
Spanish (PDF, 984 KB)

English
Hearing aid (PDF, 974 KB)
Base infertility 50% (PDF, 727 KB)
Additional infertility 50% (PDF, 727 KB)
Additional infertility 80% (PDF, 728 KB)
Additional infertility 95% (PDF, 728 KB)

Spanish
Hearing aid (PDF, 758 KB)
Base infertility 50% (PDF, 772 KB)
Additional infertility 50% (PDF, 771 KB)
Additional infertility 80% (PDF, 772 KB)
Additional infertility 95% (PDF, 772 KB)

English (PDF, 1.1 MB)
Active Choice® Classic 850 80/60 English (PDF, 882 KB)
Spanish (PDF, 984 KB)

English
Hearing aid (PDF, 974 KB)
Base infertility 50% (PDF, 727 KB)
Additional infertility 50% (PDF, 727 KB)
Additional infertility 80% (PDF, 728 KB)
Additional infertility 95% (PDF, 728 KB)

Spanish
Hearing aid (PDF, 758 KB)
Base infertility 50% (PDF, 772 KB)
Additional infertility 50% (PDF, 771 KB)
Additional infertility 80% (PDF, 772 KB)
Additional infertility 95% (PDF, 772 KB)

English (PDF, 1.1 MB)
Not marketed PPO plans* Summary of Benefits Optional benefits Disclosures
Shield Spectrum PPOSM 250-90/70 Standard English (PDF, 1.1 MB)
Spanish (PDF, 273 KB)

English
Hearing aid (PDF, 750 KB)
Base infertility 50% (PDF, 727 KB)
Additional infertility 50% (PDF, 727 KB)
Additional infertility 80% (PDF, 728 KB)
Additional infertility 95% (PDF, 728 KB)

Spanish
Hearing aid (PDF, 758 KB)
Base infertility 50% (PDF, 772 KB)
Additional infertility 50% (PDF, 771 KB)
Additional infertility 80% (PDF, 772 KB)
Additional infertility 95% (PDF, 772 KB)

English (PDF, 1.1 MB)
 

Added Advantage Point of Service Plans

Added Advantage POSSM plans Summary of Benefits Optional benefits Disclosures
Added Advantage POSSM 
300-100/90/70

English (PDF, 1.1 MB) 
Spanish (PDF, 1.9 MB)

 

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 (PDF, 1.2 MB)

Added Advantage POSSM 
500-100/80/60

English (PDF, 1.1 MB)
Spanish (PDF, 1.9 MB)

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 (PDF, 1.2 MB)

 

Full EPO plans Summary of Benefits Optional benefits  Disclosures
Full EPO Zero Admit 20 English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)

English
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, 1.1 MB)
Full EPO Zero Admit 30 English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)

English
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, 1.1 MB)
Full EPO Per Admit 10-250 English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)

English
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, 1.1 MB)
Full EPO Facility Coinsurance 20-20% English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)

English
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, 1.1 MB)
Full EPO 25-1500 80% English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)

English
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, 1.1 MB)
Full EPO 25-2500 80% English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)

English
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, 1.1 MB)
Tandem EPO plans Summary of Benefits Optional benefits  Disclosures
Tandem EPO Zero Admit 20 English (PDF, 977 KB)
Spanish (PDF, 169 KB)

 

English
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, 1.1 MB)
Tandem EPO Zero Admit 30 English (PDF, 977 KB)
Spanish (PDF, 169 KB)

 

English
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, 1.1 MB)
Tandem EPO Per Admit 10-250 English (PDF, 977 KB)
Spanish (PDF, 170 KB)

 

English
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, 1.1 MB)
Tandem EPO Facility Coinsurance 20-20% English (PDF, 977 KB)
Spanish (PDF, 170 KB)

 

English
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, 1.1 MB)
Tandem EPO 25-1500 80% English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)

English
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, 1.7MB)
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 EPO 25-2500 80% English (PDF, 1 MB)
Spanish (PDF, 1.7 MB)

English
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, 1.1 MB)

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