Summary of Benefits 2022

Download summary of benefits and disclosures for Blue Shield Off-Exchange Package and Blue Shield Mirror Package for Small Business.

Blue Shield Off-Exchange PPO plans

Plans	Summary of Benefits	Disclosures	Optional benefits
Platinum Full PPO 0/0 OffEx	English Spanish	English	Infertility English Spanish
Platinum Tandem PPO 0/0 OffEx	English Spanish	English	Infertility English Spanish
Platinum Full PPO 0/10 OffEx	English Spanish	English	Infertility English Spanish
Platinum Tandem PPO 0/10 OffEx	English Spanish	English	Infertility English Spanish
Platinum Full PPO 250/10 OffEx	English Spanish	English	Infertility English Spanish
Platinum Tandem PPO 250/10 OffEx	English Spanish	English	Infertility English Spanish
Platinum Full PPO 250/15 OffEx	English Spanish	English	Infertility English Spanish
Platinum Tandem PPO 250/15 OffEx	English Spanish	English	Infertility English Spanish
Gold Full PPO 0/25 OffEx	English Spanish	English	Infertility English Spanish
Gold Tandem PPO 0/25 OffEx	English Spanish	English	Infertility English Spanish
Gold Full PPO 500/30 OffEx	English Spanish	English	Infertility English Spanish
Gold Tandem PPO 500/30 OffEx	English Spanish	English	Infertility English Spanish
Gold Full PPO 750/30 OffEx	English Spanish	English	Infertility English Spanish
Gold Tandem PPO 750/30 OffEx	English Spanish	English	Infertility English Spanish
Gold Full PPO 1000/35 OffEx	English Spanish	English	Infertility English Spanish
Gold Tandem PPO 1000/35 OffEx	English Spanish	English	Infertility English Spanish
Silver Full PPO 1800/45 OffEx	English Spanish	English	Infertility English Spanish
Silver Tandem PPO 1800/45 OffEx	English Spanish	English	Infertility English Spanish
Silver Full PPO 2225/50 OffEx	English Spanish	English	Infertility English Spanish
Silver Tandem PPO 2225/50 OffEx	English Spanish	English	Infertility English Spanish
Silver Full PPO 2400/55 OffEx	English Spanish	English	Infertility English Spanish
Silver Tandem PPO 2400/55 OffEx	English Spanish	English	Infertility English Spanish
Bronze Full PPO 5500/65 OffEx	English Spanish	English	Infertility English Spanish
Bronze Tandem PPO 5500/65 OffEx	English Spanish	English	Infertility English Spanish
Bronze Full PPO 6250/65 OffEx	English Spanish	English	Infertility English Spanish
Bronze Tandem PPO 6250/65 OffEx	English Spanish	English	Infertility English Spanish
Bronze Full PPO 6500/70 OffEx	English Spanish	English	Infertility English Spanish
Bronze Tandem PPO 6500/70 OffEx	English Spanish	English	Infertility English Spanish
Bronze Full PPO 7500/65 OffEx	English Spanish	English	Infertility English Spanish
Bronze Tandem PPO 7500/65 OffEx	English Spanish	English	Infertility English Spanish
Bronze Full PPO 6850/55 OffEx	English Spanish	English	Infertility English Spanish
Bronze Tandem PPO 6850/55 OffEx	English Spanish	English	Infertility English Spanish

Blue Shield Mirror PPO plans

Plans	Summary of Benefits	Disclosures	Optional benefits
Blue Shield Platinum 90 PPO 0/15 + Child Dental	English Spanish	English	Infertility English Spanish
Blue Shield Gold 80 PPO 350/25 + Child Dental	English Spanish	English	Infertility English Spanish
Blue Shield Silver 70 PPO 2250/50 + Child Dental	English Spanish	English	Infertility English Spanish
Blue Shield Bronze 60 PPO 6300/65 + Child Dental	English Spanish	English	Infertility English Spanish

Blue Shield Off-Exchange HSA/HDHP plans

Plans	Summary of Benefits	Disclosures	Optional benefits
Gold Full PPO Savings 1750/15% HDHP PrevRx OffEx	English Spanish	English	Infertility English Spanish
Gold Tandem PPO Savings 1750/15% HDHP PrevRx OffEx	English Spanish	English	Infertility English Spanish
Silver Full PPO Savings 2100/25% OffEx	English Spanish	English	Infertility English Spanish
Silver Tandem PPO Savings 2100/25% OffEx	English Spanish	English	Infertility English Spanish
Silver Full PPO Savings 2600/35% HDHP PrevRx OffEx	English Spanish	English	Infertility English Spanish
Silver Tandem PPO Savings 2600/35% HDHP PrevRx OffEx	English Spanish	English	Infertility English Spanish
Bronze Full PPO Savings 5700/40% OffEx	English Spanish	English	Infertility English Spanish
Bronze Tandem PPO Savings 5700/40% OffEx	English Spanish	English	Infertility English Spanish
Bronze Full PPO Savings 7000 OffEx	English Spanish	English	Infertility English Spanish
Bronze Tandem PPO Savings 7000 OffEx	English Spanish	English	Infertility English Spanish

Blue Shield Off-Exchange HMO plans

Plans	Summary of Benefits	Disclosures	Optional benefits
Platinum Access+ HMO^® 0/20 OffEx	English Spanish	English	Infertility English Spanish
Platinum Local Access+ HMO^® 0/20 OffEx	English Spanish	English	Infertility English Spanish
Platinum Trio HMO 0/20 OffEx	English Spanish	English	Infertility English Spanish
Platinum Access+ HMO^® 0/25 OffEx	English Spanish	English	Infertility English Spanish
Platinum Local Access+ HMO^® 0/25 OffEx	English Spanish	English	Infertility English Spanish
Platinum Trio HMO 0/25 OffEx	English Spanish	English	Infertility English Spanish
Platinum Access+ HMO^® 0/30 OffEx	English Spanish	English	Infertility English Spanish
Platinum Local Access+ HMO^® 0/30 OffEx	English Spanish	English	Infertility English Spanish
Platinum Trio HMO 0/30 OffEx	English Spanish	English	Infertility English Spanish
Gold Access+ HMO^® 0/30 OffEx	English Spanish	English	Infertility English Spanish
Gold Local Access+ HMO^® 0/30 OffEx	English Spanish	English	Infertility English Spanish
Gold Trio HMO 0/30 OffEx	English Spanish	English	Infertility English Spanish
Gold Access+ HMO^® 500/35 OffEx	English Spanish	English	Infertility English Spanish
Gold Local Access+ HMO^® 500/35 OffEx	English Spanish	English	Infertility English Spanish
Gold Trio HMO 500/35 OffEx	English Spanish	English	Infertility English Spanish
Gold Access+ HMO^® 1000/35 OffEx	English Spanish	English	Infertility English Spanish
Gold Local Access+ HMO^® 1000/35 OffEx	English Spanish	English	Infertility English Spanish
Gold Trio HMO 1000/35 OffEx	English Spanish	English	Infertility English Spanish
Gold Access+ HMO ^® 1500/35 OffEx	English Spanish	English	Infertility English Spanish
Gold Local Access+ HMO ^® 1500/35 OffEx	English Spanish	English	Infertility English Spanish
Gold Trio HMO 1500/35 OffEx	English Spanish	English	Infertility English Spanish
Silver Access+ HMO ^® 2000/60 OffEx	English Spanish	English	Infertility English Spanish
Silver Access+ HMO ^® 2750/65 OffEx	English Spanish	English	Infertility English Spanish
Silver Local Access+ HMO ^® 2000/60 OffEx	English Spanish	English	Infertility English Spanish
Silver Local Access+ HMO ^® 2750/65 OffEx	English Spanish	English	Infertility English Spanish
Silver Trio HMO 2000/60 OffEx	English Spanish	English	Infertility English Spanish
Silver Trio HMO 2750/65 OffEx	English Spanish	English	Infertility English Spanish
Bronze Trio HMO 7000/70 OffEx	English Spanish	English	Infertility English Spanish

Blue Shield Mirror HMO plans

Plans	Summary of Benefits	Disclosures	Optional benefits
Blue Shield Trio Platinum 90 HMO 0/20 + Child Dental	English Spanish	English	Infertility English Spanish
Blue Shield Trio Gold 80 HMO 250/35 + Child Dental	English Spanish	English	Infertility English Spanish
Blue Shield Trio Silver 70 HMO 2250/55 + Child Dental	English Spanish	English	Infertility English Spanish

© California Physicians' Service DBA Blue Shield of California 1999-2024. All rights reserved. California Physicians’ Service DBA Blue Shield of California is an independent member of the Blue Shield Association. Health insurance products are offered by Blue Shield of California Life & Health Insurance Company. Health plans are offered by Blue Shield of California.

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Summary of Benefits 2022