Summary of Benefits 2022
For 2022 medical plans, the Summary of Benefits (SOBs) include coverage information in a simplified format, making it easier for members to read and understand their plan benefits. SOBs are included in renewals, open enrollment materials and member welcome kits as part of the Evidence of Coverage (EOC).
When providing a SOB to an applicant or Blue Shield member, you must also include a disclosure and a Notice of Language Assistance (PDF, 1 MB).
In addition to the SOBs, the Summary of Benefits and Coverage (SBC) Forms provide your clients with an easy-to-understand overview of what our plans for groups of 1 to 100 cover. Download SBC forms and other resources.
These SOBs are effective January 1, 2022, for small businesses of 1 to 100.
Off-exchange package for Small Business — HMO plans
| Blue Shield Off-Exchange HMO Plans | Summary of Benefits | Disclosures | Optional Benefit |
|---|---|---|---|
| Platinum Access+ HMO® 0/20 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Platinum Local Access+ HMO® 0/20 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Platinum Trio HMO 0/20 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Platinum Access+ HMO® 0/25 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Platinum Local Access+ HMO® 0/25 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Platinum Trio HMO 0/25 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Platinum Access+ HMO® 0/30 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Platinum Local Access+ HMO® 0/30 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Platinum Trio HMO 0/30 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Gold Access+ HMO® 0/30 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Gold Local Access+ HMO® 0/30 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Gold Trio HMO 0/30 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Gold Access+ HMO® 500/35 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Gold Local Access+ HMO® 500/35 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Gold Trio HMO 500/35 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Gold Access+ HMO® 1000/35 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Gold Local Access+ HMO® 1000/35 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Gold Trio HMO 1000/35 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Gold Access+ HMO® 1500/35 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Gold Local Access+ HMO® 1500/35 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Gold Trio HMO 1500/35 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Silver Access+ HMO® 2300/70 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Silver Access+ HMO® 2750/70 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Silver Local Access+ HMO® 2300/70 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Silver Local Access+ HMO® 2750/70 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Silver Trio HMO 2300/70 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Silver Trio HMO 2750/70 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Bronze Trio HMO 7000/70 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
Mirror package for Small Business — HMO plans
| Blue Shield Mirror HMO Plans | Summary of Benefits | Disclosures | Optional Benefit |
|---|---|---|---|
| Blue Shield Trio Platinum 90 HMO 0/20 + Child Dental |
English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Blue Shield Trio Gold 80 HMO 250/35 + Child Dental |
English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Blue Shield Trio Silver 70 HMO 2250/55 + Child Dental |
English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
Off-exchange package for Small Business — PPO plans
| Blue Shield Off-Exchange PPO Plans | Summary of Benefits | Disclosures | Optional Benefit |
|---|---|---|---|
| Platinum Full PPO 0/0 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.8MB) |
English (PDF, 1.1MB) |
Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB) |
| Platinum Tandem PPO 0/0 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.8MB) |
English (PDF, 1.1MB) |
Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB) |
| Platinum Full PPO 0/10 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.8MB) |
English (PDF, 1.1MB) |
Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB) |
| Platinum Tandem PPO 0/10 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.8MB) |
English (PDF, 1.1MB) |
Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB) |
| Platinum Full PPO 250/10 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.8MB) |
English (PDF, 1.1MB) |
Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB) |
| Platinum Tandem PPO 250/10 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.8MB) |
English (PDF, 1.1MB) |
Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB) |
| Platinum Full PPO 250/15 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.8MB) |
English (PDF, 1.1MB) |
Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB) |
| Platinum Tandem PPO 250/15 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.9MB) |
English (PDF, 1.1MB) |
Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB) |
| Gold Full PPO 0/25 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.8MB) |
English (PDF, 1.1MB) |
Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB) |
| Gold Tandem PPO 0/25 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.8MB) |
English (PDF, 1.1MB) |
Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB) |
| Gold Full PPO 500/30 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.8MB) |
English (PDF, 1.1MB) |
Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB) |
| Gold Tandem PPO 500/30 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.9MB) |
English (PDF, 1.1MB) |
Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB) |
| Gold Full PPO 750/30 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.8MB) |
English (PDF, 1.1MB) |
Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB) |
| Gold Tandem PPO 750/30 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.9MB) |
English (PDF, 1.1MB) |
Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB) |
| Gold Full PPO 1000/35 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.8MB) |
English (PDF, 1.1MB) |
Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB) |
| Gold Tandem PPO 1000/35 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.9MB) |
English (PDF, 1.1MB) |
Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB) |
| Silver Full PPO 1800/45 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.8MB) |
English (PDF, 1.1MB) |
Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB) |
| Silver Tandem PPO 1800/45 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.9MB) |
English (PDF, 1.1MB) |
Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB) |
| Silver Full PPO 2225/50 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.8MB) |
English (PDF, 1.1MB) |
Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB) |
| Silver Tandem PPO 2225/50 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.9MB) |
English (PDF, 1.1MB) |
Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB) |
| Silver Full PPO 2400/55 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.8MB) |
English (PDF, 1.1MB) |
Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB) |
| Silver Tandem PPO 2400/55 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.9MB) |
English (PDF, 1.1MB) |
Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB) |
| Bronze Full PPO 5500/65 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.9MB) |
English (PDF, 1.1MB) |
Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB) |
| Bronze Tandem PPO 5500/65 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.9MB) |
English (PDF, 1.1MB) |
Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB) |
| Bronze Full PPO 6250/65 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.9MB) |
English (PDF, 1.1MB) |
Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB) |
| Bronze Tandem PPO 6250/65 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.9MB) |
English (PDF, 1.1MB) |
Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB) |
| Bronze Full PPO 6500/70 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.9MB) |
English (PDF, 1.1MB) |
Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB) |
| Bronze Tandem PPO 6500/70 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.9MB) |
English (PDF, 1.1MB) |
Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB) |
| Bronze Full PPO 7500/65 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.9MB) |
English (PDF, 1.1MB) |
Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB) |
| Bronze Tandem PPO 7500/65 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.9MB) |
English (PDF, 1.1MB) |
Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB) |
| Bronze Full PPO 6850/55 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.9MB) |
English (PDF, 1.1MB) |
Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB) |
| Bronze Tandem PPO 6850/55 OffEx | English (PDF, 1.1MB) Spanish (PDF, 1.9MB) |
English (PDF, 1.1MB) |
Infertility English (PDF, 996.7KB) Spanish (PDF, 1.7MB) |
Mirror package for Small Business — PPO plans
| Blue Shield Mirror PPO Plans | Summary of Benefits | Disclosures | Optional Benefit |
|---|---|---|---|
| Blue Shield Platinum 90 PPO 0/15 + Child Dental |
English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Blue Shield Gold 80 PPO 350/25 + Child Dental |
English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Blue Shield Silver 70 PPO 2250/50 + Child Dental |
English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Blue Shield Bronze 60 PPO 6300/65 + Child Dental |
English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
Off-exchange package for Small Business — HSA/HDHP plans
| Blue Shield Off-Exchange HSA HDHP Plans | Summary of Benefits | Disclosures | Optional Benefit |
|---|---|---|---|
| Gold Full PPO Savings 1750/15% HDHP PrevRx OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Gold Tandem PPO Savings 1750/15% HDHP PrevRx OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Silver Full PPO Savings 2100/25% OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Silver Tandem PPO Savings 2100/25% OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Silver Full PPO Savings 2600/35% HDHP PrevRx OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Silver Tandem PPO Savings 2600/35% HDHP PrevRx OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Bronze Full PPO Savings 5700/40% OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Bronze Tandem PPO Savings 5700/40% OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Bronze Full PPO Savings 7000 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
| Bronze Tandem PPO Savings 7000 OffEx | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
English (PDF, 1.1 MB) | Infertility English (PDF, 997 KB) Spanish (PDF, 1.7 MB) |
