2021

2021 Vision Benefit Summaries

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Plan Information Cards

For California members – English |  For California members – Spanish 

Benefit Summaries

The following benefit summaries are for groups of 101 or more employees.

When providing a benefit summary to an applicant or Blue Shield member, you must also include a Notice of Language Assistance. (PDF, 1MB)

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Vision Plans Benefit Summary Disclosures
Vision Deluxe 0/0/120 English          Spanish Disclosure
Vision Deluxe 0/0/130 English          Spanish Disclosure
Vision Deluxe 0/25/130 English          Spanish Disclosure
Vision Deluxe 0/0/150 English          Spanish Disclosure
Vision Deluxe 10/25/120 English          Spanish Disclosure
Vision Deluxe 10/25/150 English          Spanish Disclosure
Vision Deluxe 15/25/120 English          Spanish Disclosure
Vision Deluxe 15/25/130 English          Spanish Disclosure
Vision Deluxe 15/25/150 English          Spanish Disclosure
Vision Deluxe with Contacts 0/0/150/120 English          Spanish Disclosure
Vision Deluxe with Contact Lens and Fitting 10/25/150/130 English          Spanish Disclosure
Vision Deluxe with Contacts 15/25/150/120 English          Spanish Disclosure
Vision Plus 0/0/120 English          Spanish Disclosure
Vision Plus 0/0/130 English          Spanish Disclosure
Vision Plus 0/25/130 English          Spanish Disclosure
Vision Plus 0/0/150 English          Spanish Disclosure
Vision Plus 10/25/120 English          Spanish Disclosure
Vision Plus 10/25/150 English          Spanish Disclosure
Vision Plus 15/25/120 English          Spanish Disclosure
Vision Plus 15/25/130 English          Spanish Disclosure
Vision Plus 15/25/150 English          Spanish Disclosure
Vision Plus with Contacts 0/0/150/120 English          Spanish Disclosure
Vision Plus with Contacts 15/25/150/120 English          Spanish Disclosure
Vision Plus with Contact Lens and Fitting 10/25/150/130 English          Spanish Disclosure
Vision Standard with Contacts 0/0/150/120 English          Spanish Disclosure
Vision Standard with Contact Lens and Fitting 10/25/150/130 English          Spanish Disclosure
Vision Standard with Contacts 15/25/150/120 English          Spanish Disclosure
Vision Standard 0/0/120 English          Spanish Disclosure
Vision Standard 0/0/130 English          Spanish Disclosure
Vision Standard 0/25/130 English          Spanish Disclosure
Vision Standard 0/0/150 English          Spanish Disclosure
Vision Standard 10/25/120 English          Spanish Disclosure
Vision Standard 10/25/150 English          Spanish Disclosure
Vision Standard 15/25/120 English          Spanish Disclosure
Vision Standard 15/25/130 English          Spanish Disclosure
Vision Standard 15/25/150 English          Spanish Disclosure
Eye Exam Only English          Spanish Disclosure

 

Voluntary Vision Plans Benefit Summary Disclosures
Vision Deluxe Voluntary 10/25/130 English          Spanish Disclosure
Vision Deluxe Voluntary 15/25/150 English          Spanish Disclosure
Vision Plus Voluntary 10/25/130 English          Spanish Disclosure
Vision Plus Voluntary 15/25/120 English          Spanish Disclosure
Vision Standard Voluntary 10/25/130 English          Spanish Disclosure
Vision Standard Voluntary 15/25/120 English          Spanish Disclosure

 

Not Marketed Vision Plans Benefit Summary Disclosures
Vision Deluxe 0/0/100 English          Spanish Disclosure
Vision Deluxe 0/15/130 English          Spanish Disclosure
Vision Deluxe 0/25/120 English          Spanish Disclosure
Vision Plus 0/0/100 English          Spanish Disclosure
Vision Plus 0/15/120 English          Spanish Disclosure
Vision Plus 0/15/130 English          Spanish Disclosure
Vision Plus 0/25/100 English          Spanish Disclosure
Vision Plus 0/25/120 English          Spanish Disclosure
Vision Plus 10/0/100 English          Spanish Disclosure
Vision Plus 10/0/75 English          Spanish Disclosure
Vision Standard 0/0/100 English          Spanish Disclosure
Vision Standard 0/0/75 English          Spanish Disclosure
Vision Standard 0/15/120 English          Spanish Disclosure
Vision Standard 0/15/130 English          Spanish Disclosure
Vision Standard 0/25/100 English          Spanish Disclosure
Vision Standard 0/25/120 English          Spanish Disclosure
Vision Standard 10/0/100 English          Spanish Disclosure
Vision Standard 10/0/75 English          Spanish Disclosure
Vision Standard Voluntary 0/25/120 English          Spanish Disclosure
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Plan Name Benefit Summary Disclosures
Vision Standard Materials only -/15/120 (PDF, 47KB)

English  Spanish

 Disclosure

                               

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Dental and Vision Package

Plan Name Benefit Summary Disclosure

Specialty DuoSM Vision (benefit summary)

(must be purchased with Specialty Duo Dental)

 English    Spanish Disclosure

Duo Combined Disclosure

 

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