IFP Summary of Benefits 2022: Medical and Specialty
The following documents are effective January 1, 2022.
To help your clients understand their plan benefits, we have provided documents in a simplified format which will either be the Summary of Benefits (SOB) or a Benefit Summary only for specific Specialty plans. Your client will also be able to access their SOB as part of their Evidence of Coverage (EOC) or policy on blueshieldca.com/policies along with their Summary of Benefits and Coverage (SBC).
When sharing the SOB and/or Benefit Summary with your client, you must also provide the Legal Disclosure document applicable to the medical, dental or vision plan.
Trio HMO plans
Click here for disclosure.
| Trio HMO plans | Summary of Benefits |
|---|---|
| Blue Shield Platinum 90 Trio HMO | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
| Blue Shield Gold 80 Trio HMO | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
| Blue Shield Silver 70 Trio HMO | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
| Silver 70 Off Exchange Trio HMO | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
| Blue Shield Bronze 7500 Trio HMO | English (PDF, 1 MB) Spanish (PDF, 1.8 MB) |
We offer three Silver Trio HMO cost-sharing reduction plans through Covered California for clients whose income is between 138% to 250% of the federal poverty level (FPL). These plans are available only through Covered California.
PPO plans
Click here for disclosure.
| PPO plans | Summary of Benefits |
|---|---|
| Blue Shield Platinum 90 PPO | English (PDF, 1.1 MB) Spanish (PDF, 1.9 MB) |
| Blue Shield Gold 80 PPO | English (PDF, 1.1 MB) Spanish (PDF, 1.9 MB) |
| Blue Shield Silver 70 PPO | English (PDF, 1.1 MB) Spanish (PDF, 1.9 MB) |
| Silver 70 Off Exchange PPO | English (PDF, 1.1 MB) Spanish (PDF, 1.9 MB) |
| Silver 1750 PPO | English (PDF, 1.1 MB) Spanish (PDF, 1.9 MB) |
| Silver 2600 HDHP PPO | English (PDF, 1.1 MB) Spanish (PDF, 1.9 MB) |
| Blue Shield Bronze 60 PPO | English (PDF, 1.1 MB) Spanish (PDF, 1.8 MB) |
| Blue Shield Bronze 60 HDHP PPO | English (PDF, 1.1 MB) Spanish (PDF, 1.9 MB) |
| Blue Shield Minimum Coverage PPO | English (PDF, 1.1 MB) Spanish (PDF, 1.9 MB) |
We offer three Silver PPO cost-sharing reduction plans through Covered California for clients whose income is between 138% to 250% of the federal poverty level (FPL). These plans are available only through Covered California.
Alaska Native and American Indian plans
We offer American Indian and Alaska Native plans for each metal level that are available only to eligible American Indians and Alaska Natives through Covered California. These plans differ from the standard metal level plans in that they allow American Indian and Alaska Native members to access covered services from American Indian and Alaskan Native providers for no out-of-pocket costs. In addition to the Alaska Native and American Indian versions of the standard metal level plans, we offer a $0 cost share PPO plan to American Indian and Alaska Native members who qualify based on household income. Members can choose to access covered services through a Blue Shield participating provider or non-network provider for an out-of-pocket cost.
Click here for disclosure.
| Alaska Native and American Indian Trio HMO Plans | Summary of Benefits |
|---|---|
| Blue Shield Platinum 90 Trio HMO AI-AN | English (PDF, 1.1 MB) Spanish (PDF, 1.8 MB) |
| Blue Shield Gold 80 Trio HMO AI-AN | English (PDF, 1.1 MB) Spanish (PDF, 1.8 MB) |
| Blue Shield Silver 70 Trio HMO AI-AN | English (PDF, 1.1 MB) Spanish (PDF, 1.8 MB) |
| Blue Shield $0 Cost Share Trio HMO AI-AN | English (PDF, 1.1 MB) Spanish (PDF, 1.8 MB) |
| Alaska Native and American Indian PPO Plans | Summary of Benefits |
|---|---|
| Blue Shield Platinum 90 PPO AI-AN | English (PDF, 1 MB) Spanish (PDF, 1.9 MB) |
| Blue Shield Gold 80 PPO AI-AN | English (PDF, 1.1 MB) Spanish (PDF, 1.9 MB) |
| Blue Shield Silver 70 PPO AI-AN | English (PDF, 1.1 MB) Spanish (PDF, 1.9 MB) |
| Blue Shield Bronze 60 PPO AI-AN | English (PDF, 1.1 MB) Spanish (PDF, 1.9 MB) |
| Blue Shield Bronze 60 HDHP PPO AI-AN | English (PDF, 1.1 MB) Spanish (PDF, 1.9 MB) |
| Blue Shield $0 Cost Share PPO AI-AN | English (PDF, 1.1 MB) Spanish (PDF, 1.9 MB) |
Specialty plans
Summary of Benefits are available for dental plans while Benefit Summaries are available for vision plans. Dental and vision plans sold through Blue Shield can be purchased with a Blue Shield medical plan or as stand-alone policies. Family Dental Plans are sold only through Covered California and can only be purchased when enrolling in a medical plan sold through Covered California.
Dental plans underwritten by DMHC
Click here for disclosure.
| Plan name | Summary of Benefits |
|---|---|
| Dental PPO | English (PDF, 1 MB) Spanish (PDF, 1.9 MB) |
| Enhanced Dental PPO 50/1250 | English (PDF, 1.1 MB) Spanish (PDF, 1.8 MB) |
| Enhanced Dental PPO 50/2000 | English (PDF, 1.1 MB) Spanish (PDF, 1.8 MB) |
| Enhanced Dental PPO 50/2000 Lifetime Ortho 1500 | English (PDF, 1.1 MB) Spanish (PDF, 1.9 MB) |
| Dental HMO | English (PDF, 1.1 MB) Spanish (PDF, 1.8 MB) |
| Dental Standard HMO | English (PDF, 1.8 MB) Spanish (PDF, 1.9 MB) |
Dental plans underwritten by CDI
Click here for disclosure.
Family Dental Plans (sold exclusively through Covered California) - Underwritten by DMHC
Click here for disclosure.
Vision plans underwritten by CDI
Click here for disclosure.
