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Submission: On October 22 via api from US — Scanned from US
Submission: On October 22 via api from US — Scanned from US
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* Be a Blue Shield of CA Broker
1. Broker
2. Small Business
3. Small Business medical plans
4. Summary of Benefits
1. Small Business
2. Small Business medical plans
SUMMARY OF BENEFITS 2024
For 2024 medical plans, the Summary of Benefits (SOBs) include coverage
information in a simplified format, making it easier for members to read and
understand their plan benefits. SOBs are included in renewals, open enrollment
materials and member welcome kits as part of the Evidence of Coverage (EOC).
When providing a SOB to an applicant or Blue Shield member, you must also
include a disclosure and a Notice of Language Assistance (PDF, 1.1 MB).
In addition to the SOBs, the Summary of Benefits and Coverage (SBC) Forms
provide your clients with an easy-to-understand overview of what our plans for
groups of 1 to 100 cover. Click here to download SBC forms and other resources.
These SOBs are effective January 1, 2024, for small businesses of 1 to 100.
* Broker resources
* Summary of Benefits 2025
* Summary of Benefits 2024
* Summary of Benefits 2023
* Evidence of Coverage
* SBC forms and other resources
* Sales resources and collateral
* Rates
* Changes to documents
* Dental plans
* Vision plans
* Life and AD&D plans
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® 0/35 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® 0/35 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 0/35 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® 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, 97 KB)
Spanish (PDF, 1.7 MB) Gold Local Access+ HMO® 1500/35 OffEx English (PDF, 1 MB)
Spanish (PDF, 1.8 MB) English (PDF, 1.1 MB)
Infertility
English (PDF, 997 KB)
Spanish (PDF, 1.7 MB) Gold Trio HMO 1500/35 OffEx English (PDF, 49 KB)
Spanish (PDF, 49 KB) English (PDF, 1.1 MB)
Infertility
English (PDF, 997 KB)
Spanish (PDF, 1.7 MB) Silver Access+ HMO® 2300/70 OffEx English (PDF, 1 MB)
Spanish (PDF, 1.8 MB) English (PDF, 1.1 MB)
Infertility
English (PDF, 997 KB)
Spanish (PDF, 1.7 MB) Silver Access+ HMO® 2750/70 OffEx English (PDF, 1 MB)
Spanish (PDF, 1.8 MB) English (PDF, 1.1 MB)
Infertility
English (PDF, 997 KB)
Spanish (PDF, 1.7 MB) Silver Local Access+ HMO® 2300/70 OffEx English (PDF, 1
MB)
Spanish (PDF, 1.8 MB) English (PDF, 1.1 MB)
Infertility
English (PDF, 997 KB)
Spanish (PDF, 1.7 MB) Silver Local Access+ HMO® 2750/70 OffEx English (PDF, 1
MB)
Spanish (PDF, 1.8 MB) English (PDF, 1.1 MB)
Infertility
English (PDF, 997 KB)
Spanish (PDF, 1.7 MB) Silver Trio HMO 2300/70 OffEx English (PDF, 1 MB)
Spanish (PDF, 1.8 MB) English (PDF, 1.1 MB)
Infertility
English (PDF, 997 KB)
Spanish (PDF, 1.7 MB) Silver Trio HMO 2750/70 OffEx English (PDF, 1 MB)
Spanish (PDF, 1.8 MB) English (PDF, 1.1 MB)
Infertility
English (PDF, 997 KB)
Spanish (PDF, 1.7 MB) Bronze Access+ HMO® 7000/70 OffEx English (PDF, 1 MB)
Spanish (PDF, 1.8 MB) English (PDF, 1.1 MB)
Infertility
English (PDF, 997 KB)
Spanish (PDF, 1.7 MB) Bronze Local Access+ HMO 7000/70 OffEx English (PDF, 1 MB)
Spanish (PDF, 1.8 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, 1MB)
Spanish (PDF, 1.8MB) English (PDF, 1.1MB)
Infertility
English (PDF, 1.0MB)
Spanish (PDF, 1.7MB) Blue Shield Trio Gold 80 HMO 250/35
+ Child Dental English (PDF, 1MB)
Spanish (PDF, 1.8MB) English (PDF, 1.1MB)
Infertility
English (PDF, 1.0MB)
Spanish (PDF, 1.7MB) Blue Shield Trio Silver 70 HMO 2500/55
+ Child Dental English (PDF, 1MB)
Spanish (PDF, 1.8MB) English (PDF, 1.1MB)
Infertility
English (PDF, 1.0MB)
Spanish (PDF, 1.7MB) Blue Shield Access+ Gold 80 HMO® 250/35 + Child Dental
English (PDF, 227KB)
Spanish (PDF, 276KB) English (PDF, 311KB)
Infertility
English (PDF, 1.0MB)
Spanish (PDF, 1.7MB) Blue Shield Access+ Platinum 90 HMO® 0/20 + Child Dental
English (PDF, 218KB)
Spanish (PDF, 263KB) English (PDF, 311KB)
Infertility
English (PDF, 1.0MB)
Spanish (PDF, 1.7MB) Blue Shield Access+ Silver 70 HMO® 2500/55 + Child Dental
English (PDF, 220KB)
Spanish (PDF, 267KB) English (PDF, 311KB)
Infertility
English (PDF, 1.0MB)
Spanish (PDF, 1.7MB) Blue Shield Trio Bronze 60 HMO® 7000/70 + Child Dental Alt
English (PDF, 231KB)
Spanish (PDF, 271KB) English (PDF, 311KB)
Infertility
English (PDF, 1.0MB)
Spanish (PDF, 1.7MB)
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, 997KB)
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, 997KB)
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, 997KB)
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, 997KB)
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, 997KB)
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, 997KB)
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, 997KB)
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, 997KB)
Spanish (PDF, 1.7MB) Gold Full PPO 0/35 OffEx English (PDF, 1.1MB)
Spanish (PDF, 1.8MB) English (PDF, 1.1MB)
Infertility
English (PDF, 997KB)
Spanish (PDF, 1.7MB) Gold Tandem PPO 0/35 OffEx English (PDF, 1.1MB)
Spanish (PDF, 1.8MB) English (PDF, 1.1MB)
Infertility
English (PDF, 997KB)
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, 997KB)
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, 997KB)
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, 997KB)
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, 997KB)
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, 997KB)
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, 997KB)
Spanish (PDF, 1.7MB) Silver Full PPO 2000/60 OffEx English (PDF, 1.1MB)
Spanish (PDF, 1.8MB) English (PDF, 1.1MB)
Infertility
English (PDF, 997KB)
Spanish (PDF, 1.7MB) Silver Tandem PPO 2000/60 OffEx English (PDF, 1.1MB)
Spanish (PDF, 1.9MB) English (PDF, 1.1MB)
Infertility
English (PDF, 997KB)
Spanish (PDF, 1.7MB) Silver Full PPO 2350/65 OffEx English (PDF, 1.1MB)
Spanish (PDF, 1.8MB) English (PDF, 1.1MB)
Infertility
English (PDF, 997KB)
Spanish (PDF, 1.7MB) Silver Tandem PPO 2350/65 OffEx English (PDF, 1.1MB)
Spanish (PDF, 1.9MB) English (PDF, 1.1MB)
Infertility
English (PDF, 997KB)
Spanish (PDF, 1.7MB) Silver Full PPO 2550/70 OffEx English (PDF, 1.1MB)
Spanish (PDF, 1.8MB) English (PDF, 1.1MB)
Infertility
English (PDF, 997KB)
Spanish (PDF, 1.7MB) Silver Tandem PPO 2550/70 OffEx English (PDF, 1.1MB)
Spanish (PDF, 1.9MB) English (PDF, 1.1MB)
Infertility
English (PDF, 997KB)
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, 997KB)
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, 997KB)
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, 997KB)
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, 997KB)
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, 997KB)
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, 997KB)
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, 997KB)
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, 997KB)
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, 997KB)
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, 997KB)
Spanish (PDF, 1.7MB)
Virtual Blue Plans Summary of Benefits Disclosures Optional Benefit Virtual
Blue℠ Gold Tandem PPO 1500/45 OffEx English (PDF, 275KB)
Spanish (PDF, 344KB) English (PDF, 310KB)
Infertility
English (PDF, 997KB)
Spanish (PDF, 1.7MB) Virtual Blue℠ Bronze Tandem PPO 7500/75 OffEx English (PDF,
288KB)
Spanish (PDF, 353KB) English (PDF, 310KB)
Infertility
English (PDF, 997KB)
Spanish (PDF, 1.7MB) Virtual Blue℠ Platinum Tandem PPO 250/20 OffEx
English (PDF, 288KB)
Spanish (PDF, 353KB) English (PDF, 310KB)
Infertility
English (PDF, 997KB)
Spanish (PDF, 1.7MB) Virtual Blue℠ Silver Tandem PPO 2700/75 OffEx English (PDF,
288KB)
Spanish (PDF, 353KB) English (PDF, 310KB)
Infertility
English (PDF, 997KB)
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, 1.1 MB)
Spanish (PDF, 1.8 MB) English (PDF, 1.1 MB)
Infertility
English (PDF, 1 MB)
Spanish (PDF, 1.7 MB) Blue Shield Gold 80 PPO 350/25
+ Child Dental English (PDF, 1.1 MB)
Spanish (PDF, 1.8 MB) English (PDF, 1.1 MB)
Infertility
English (PDF, 1 MB)
Spanish (PDF, 1.7 MB) Blue Shield Silver 70 PPO 2500/55 + Child Dental
English (PDF, 1.1 MB)
Spanish (PDF, 1.8 MB) English (PDF, 1.1 MB)
Infertility
English (PDF, 1 MB)
Spanish (PDF, 1.7 MB) Blue Shield Bronze 60 PPO 6300/60 + Child Dental
English (PDF, 1.1 MB)
Spanish (PDF, 1.9 MB) English (PDF, 1.1 MB)
Infertility
English (PDF, 1 MB)
Spanish (PDF, 1.7 MB) Blue Shield Bronze 60 HDHP PPO 7500/0% + Child Dental Alt
English (PDF, 257 KB)
Spanish (PDF, 330 KB) English (PDF, 340 KB)
Infertility
English (PDF, 1 MB)
Spanish (PDF, 1.7 MB) Blue Shield Silver 70 HDHP PPO 2300/30% + Child Dental Alt
English (PDF, 267 KB)
Spanish (PDF, 331 KB) English (PDF, 340 KB)
Infertility
English (PDF, 1 MB)
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, 1.9 MB) English (PDF, 1.1 MB)
Infertility
English (PDF, 997 KB)
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Spanish (PDF, 1.7 MB) Bronze Tandem PPO Savings 5700/40% OffEx English (PDF, 1
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Spanish (PDF, 1.9 MB) English (PDF, 1.1 MB)
Infertility
English (PDF, 997 KB)
Spanish (PDF, 1.7 MB) Bronze Full PPO Savings 7500 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 7500 OffEx English (PDF, 1 MB)
Spanish (PDF, 1.8 MB) English (PDF, 1.1 MB)
Infertility
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Spanish (PDF, 1.7 MB)
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