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Plan Documents for Blue Shield of California PPO

Plan Documents for Blue Shield of California PPO

Visit Blue Shield of California's SFHSS website here.

Find in-network providers within California here.

Find providers outside of California using the national network of Blue Cross Blue Shield providers here and enter the prefix SFG.

Blue Shield Connect will replace Accolade. For more information contact:

PPO plan
(866) 336-0711
Nurse support: 24/7
Other help: 8 a.m. - 8 p.m. PT; M - F

Blue Shield of California PPO

2024 Blue Shield of PPO Plan Documents

Active Employees and Early Retirees (California)
2024 Blue Shield of CA PPO - Summary of Benefits (Active/Early Retiree) (207.76 KB)
2024 Blue Shield of CA PPO – Summary of Benefits & Coverage (Active/Early Retiree) (384.65 KB)
2024 Blue Shield of CA PPO - Evidence of Coverage/Summary of Plan Description (EOC/SPD) (Active/Early Retiree) (1.20 MB)
Active Employees and Early Retirees (Out of Area)
2024 Blue Shield PPO - Out of Area Summary of Benefits (Out of United States Retiree) (387.33 KB)
2024 Blue Shield PPO - Out of Area Summary of Benefits & Coverage (Out of United States Retiree) (387.33 KB)
2024 Blue Shield PPO - Out of Area Evidence of Coverage/Summary of Plan Description (EOC/SPD) (Out of United States Retiree) (972.86 KB)
Blue Shield of CA PPO 20 for Medicare-Eligible Retirees Who Do Not Enroll in Medicare
2024 Blue Shield of CA PPO-20 Summary of Benefits (Retiree-Medicare Eligible Not Enrolled) (208.76 KB)
2024 Blue Shield of CA PPO-20 Summary of Benefits & Coverage (Retiree-Medicare Eligible Not Enrolled) (384.79 KB)
2024 Blue Shield of CA PPO-20 Evidence of Coverage/Summary of Plan Description (EOC/SPD) (Retiree-Medicare Eligible Not Enrolled) (1.09 MB)
Claim Forms
Blue Shield of CA Medical Claim Form - USA Only (450.00 KB)
Blue Shield of CA RX Claim Form US and International (217.89 KB)
Blue Shield of CA International Medical Claim Form (133.75 KB)

2025 Blue Shield PPO Plan Documents

2025 Active Employees and Early Retirees (California)
2025 Blue Shield PPO - Summary of Benefits - Actives and Early Retirees (266.26 KB)
2025 Blue Shield PPO - Summary of Benefits & Coverage - Actives and Early Retirees (467.87 KB)
2025 Blue Shield PPO - Evidence of Coverage- Summary of Plan Description - Actives and Early Retirees (1.19 MB)
Blue Shield of CA PPO 20 for Medicare-Eligible Retirees Who Do Not Enroll in Medicare
Blue Shield PPO 20 - Summary of Benefits - Retiree - Medicare Eligible Not Enrolled (267.38 KB)
Blue Shield PPO 20 - Summary of Benefits & Coverage - Retiree - Medicare Eligible Not Enrolled (466.08 KB)
Blue Shield PPO 20 - Evidence of Coverage/Summary of Plan Description - Retiree - Medicare Eligible Not Enrolled (1.18 MB)
2025 Active Employees and Early Retirees (Out of Area)
2025 Blue Shield PPO - Out of Area - Summary of Benefits (267.85 KB)
2025 Blue Shield PPO - Out of Area - Summary of Benefits & Coverage (466.86 KB)
2025 Blue Shield PPO - Out of Area - Evidence of Coverage/Summary of Plan Description (1.20 MB)