Summary of Benefits 2022 - Vision
Summary of Benefits
When providing a summary of benefits to an applicant or Blue Shield member, you must also include a Disclosure and a Notice of Language Assistance. (PDF, 1 MB)
How to read plan names: Eye exam copayment/materials copayment/frame allowance. 'Plus' plans include additional benefits for contact lens materials and fitting.
Basic plans
| Plan names | Summaries of Benefits | Disclosures |
|---|---|---|
| Basic Vision for Small Business 0/0/120 | English Spanish |
English |
| Basic Vision for Small Business 0/0/150 | English Spanish |
English |
| Basic Vision for Small Business 10/25/120 | English Spanish |
English |
| Basic Vision for Small Business 10/25/150 | English Spanish |
English |
| Basic Vision Plus for Small Business 0/0/150/150 | English Spanish |
English |
| Basic Vision Plus for Small Business 10/25/150/150 | English Spanish |
English |
| Basic Vision Voluntary for Small Business 10/25/120 | English Spanish |
English |
Preferred plans
| Plan names | Summaries of Benefits | Disclosures |
|---|---|---|
| Preferred Vision for Small Business 0/0/120 | English Spanish |
English |
| Preferred Vision for Small Business 0/0/150 | English Spanish |
English |
| Preferred Vision for Small Business 10/25/120 | English Spanish |
English |
| Preferred Vision for Small Business 10/25/150 | English Spanish |
English |
| Preferred Vision Plus for Small Business 0/0/150/150 | English Spanish |
English |
| Preferred Vision Plus for Small Business 10/25/150/150 | English Spanish |
English |
| Preferred Vision Voluntary for Small Business 10/25/120 | English Spanish |
English |
Ultimate plans
| Plan names | Summaries of Benefits | Disclosures |
|---|---|---|
| Ultimate Vision for Small Business 0/0/120 | English Spanish |
English |
| Ultimate Vision for Small Business 0/0/150 | English Spanish |
English |
| Ultimate Vision for Small Business 10/25/120 | English Spanish |
English |
| Ultimate Vision for Small Business 10/25/150 | English Spanish |
English |
| Ultimate Vision Plus for Small Business 0/0/150/150 | English Spanish |
English |
| Ultimate Vision Plus for Small Business 10/25/150/150 | English Spanish |
English |
| Ultimate Vision Voluntary for Small Business 10/25/150 | English Spanish |
English |
Closed Vision plans – 2022: for renewing groups only
| Plan names | Summaries of Benefits | Disclosures |
|---|---|---|
Ultimate Vision for Small Business 15/25/120 |
English Spanish |
English |
| Ultimate Vision Plus for Small Business 15/25/150/150 | English Spanish |
English |
| Ultimate Vision Voluntary for Small Business 15/25/150 | English Spanish |
English |
| Ultimate Vision for Small Business 15/25/150 | English Spanish |
English |
| Preferred Vision Plus for Small Business 15/25/150/150 | English Spanish |
English |
| Preferred Vision Voluntary for Small Business 15/25/120 | English Spanish |
English |
| Preferred Vision for Small Business 15/25/120 | English Spanish |
English |
| Preferred Vision for Small Business 15/25/150 | English Spanish |
English |
| Basic Vision for Small Business 15/25/120 | English Spanish |
English |
| Basic Vision for Small Business 15/25/150 | English Spanish |
English |
| Basic Vision Plus for Small Business 15/25/150/150 | English Spanish |
English |
| Basic Vision Voluntary for Small Business 15/25/120 | English Spanish |
English |
