Summary of Benefits 2022 - Vision
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, 1 MB)
2022 Vision Summary of Benefits
| Plan name | Summary of Benefits | Disclosure |
|---|---|---|
| Vision Deluxe 0/0/120 | English (PDF, 740 KB) Spanish (PDF, 787 KB) |
Disclosure (PDF, 808 KB) |
| Vision Deluxe 0/0/130 | English (PDF, 740 KB) Spanish (PDF, 787 KB) |
Disclosure (PDF, 808 KB) |
| Vision Deluxe 0/25/130 | English (PDF, 742 KB) Spanish (PDF, 787 KB) |
Disclosure (PDF, 808 KB) |
| Vision Deluxe 0/0/150 | English (PDF, 742 KB) Spanish (PDF, 790 KB) |
Disclosure (PDF, 808 KB) |
| Vision Deluxe 10/25/120 | English (PDF, 742 KB) Spanish (PDF, 789 KB) |
Disclosure (PDF, 808 KB) |
| Vision Deluxe 10/25/150 | English (PDF, 742 KB) Spanish (PDF, 790 KB) |
Disclosure (PDF, 808 KB) |
| Vision Deluxe 15/25/120 | English (PDF, 742 KB) Spanish (PDF, 789 KB) |
Disclosure (PDF, 808 KB) |
| Vision Deluxe 15/25/130 | English (PDF, 742 KB) Spanish (PDF, 790 KB) |
Disclosure (PDF, 808 KB) |
| Vision Deluxe 15/25/150 | English (PDF, 743 KB) Spanish (PDF, 790 KB) |
Disclosure (PDF, 808 KB) |
| Vision Deluxe with Contacts 0/0/150/150 | English (PDF, 742 KB) Spanish (PDF, 788 KB) |
Disclosure (PDF, 808 KB) |
| Vision Deluxe with Contact Lens and Fitting 10/25/150/150 | English (PDF, 742 KB) Spanish (PDF, 791 KB) |
Disclosure (PDF, 808 KB) |
| Vision Deluxe with Contacts 15/25/150/150 | English (PDF, 743 KB) Spanish (PDF, 791 KB) |
Disclosure (PDF, 808 KB) |
| Vision Plus 0/0/120 | English (PDF, 740 KB) Spanish (PDF, 787 KB) |
Disclosure (PDF, 808 KB) |
| Vision Plus 0/0/130 | English (PDF, 740 KB) Spanish (PDF, 787 KB) |
Disclosure (PDF, 808 KB) |
| Vision Plus 0/25/130 | English (PDF, 742 KB) Spanish (PDF, 791 KB) |
Disclosure (PDF, 808 KB) |
| Vision Plus 0/0/150 | English (PDF, 740 KB) Spanish (PDF, 788 KB) |
Disclosure (PDF, 808 KB) |
| Vision Plus 10/25/120 | English (PDF, 743 KB) Spanish (PDF, 789 KB) |
Disclosure (PDF, 808 KB) |
| Vision Plus 10/25/150 | English (PDF, 743 KB) Spanish (PDF, 791 KB) |
Disclosure (PDF, 808 KB) |
| Vision Plus 15/25/120 | English (PDF, 743 KB) Spanish (PDF, 789 KB) |
Disclosure (PDF, 808 KB) |
| Vision Plus 15/25/130 | English (PDF, 743 KB) Spanish (PDF, 791 KB) |
Disclosure (PDF, 808 KB) |
| Vision Plus 15/25/150 | English (PDF, 743 KB) Spanish (PDF, 791 KB) |
Disclosure (PDF, 808 KB) |
| Vision Plus with Contacts 0/0/150/150 | English (PDF, 740 KB) Spanish (PDF, 788 KB) |
Disclosure (PDF, 808 KB) |
| Vision Plus with Contacts 15/25/150/150 | English (PDF, 740 KB) Spanish (PDF, 791 KB) |
Disclosure (PDF, 808 KB) |
| Vision Plus with Contact Lens and Fitting 15/25/150/150 | English (PDF, 743 KB) Spanish (PDF, 792 KB) |
Disclosure (PDF, 808 KB) |
| Vision Standard with Contacts 0/0/150/150 | English (PDF, 742 KB) Spanish (PDF, 790 KB) |
Disclosure (PDF, 808 KB) |
| Vision Standard with Contact Lens and Fitting 10/25/150/150 | English (PDF, 740 KB) Spanish (PDF, 791 KB) |
Disclosure (PDF, 808 KB) |
| Vision Standard with Contacts 15/25/150/150 | English (PDF, 743 KB) Spanish (PDF, 791 KB) |
Disclosure (PDF, 808 KB) |
| Vision Standard 0/0/120 | English (PDF, 742 KB) Spanish (PDF, 788 KB) |
Disclosure (PDF, 808 KB) |
| Vision Standard 0/0/130 | English (PDF, 740 KB) Spanish (PDF, 787 KB) |
Disclosure (PDF, 808 KB) |
| Vision Standard 0/25/130 | English (PDF, 743 KB) Spanish (PDF, 791 KB) |
Disclosure (PDF, 808 KB) |
| Vision Standard 0/0/150 | English (PDF, 742 KB) Spanish (PDF, 788 KB) |
Disclosure (PDF, 808 KB) |
| Vision Standard 10/25/120 | English (PDF, 743 KB) Spanish (PDF, 780 KB) |
Disclosure (PDF, 808 KB) |
| Vision Standard 10/25/150 | English (PDF, 740 KB) Spanish (PDF, 791 KB) |
Disclosure (PDF, 808 KB) |
| Vision Standard 15/25/120 | English (PDF, 743 KB) Spanish (PDF, 791 KB) |
Disclosure (PDF, 808 KB) |
| Vision Standard 15/25/130 | English (PDF, 743 KB) Spanish (PDF, 791 KB) |
Disclosure (PDF, 808 KB) |
| Vision Standard 15/25/150 | English (PDF, 743 KB) Spanish (PDF, 791 KB) |
Disclosure (PDF, 808 KB) |
| Eye Exam Only | English (PDF, 728 KB) Spanish (PDF, 763 KB) |
Disclosure (PDF, 808 KB) |
| Voluntary Vision plans | Summary of Benefits | Disclosures |
|---|---|---|
| Vision Deluxe Voluntary 10/25/130 | English (PDF, 742 KB) Spanish (PDF, 791 KB) |
Disclosure (PDF, 808 KB) |
| Vision Deluxe Voluntary 15/25/150 | English (PDF, 742 KB) Spanish (PDF, 790 KB) |
Disclosure (PDF, 808 KB) |
| Vision Plus Voluntary 10/25/130 | English (PDF, 743 KB) Spanish (PDF, 791 KB) |
Disclosure (PDF, 808 KB) |
| Vision Plus Voluntary 15/25/120 | English (PDF, 743 KB) Spanish (PDF, 790 KB) |
Disclosure (PDF, 808 KB) |
| Vision Standard Voluntary 10/25/130 | English (PDF, 743 KB) Spanish (PDF, 791 KB) |
Disclosure (PDF, 808 KB) |
| Vision Standard Voluntary 15/25/120 | English (PDF, 743 KB) Spanish (PDF, 790 KB) |
Disclosure (PDF, 808 KB) |
| Not Marketed Vision plans | Summary of Benefits | Disclosure |
|---|---|---|
| Vision Deluxe 0/15/130 | English (PDF, 742 KB) Spanish (PDF, 790 KB) |
Disclosure (PDF, 808 KB) |
| Vision Plus 0/15/130 | English (PDF, 740 KB) Spanish (PDF, 780 KB) |
Disclosure (PDF, 808 KB) |
| Vision Plus 0/25/120 | English (PDF, 742 KB) Spanish (PDF, 789 KB) |
Disclosure (PDF, 808 KB) |
| Vision Plus 10/0/100 | English (PDF, 740 KB) Spanish (PDF, 787 KB) |
Disclosure (PDF, 808 KB) |
| Vision Standard 0/0/100 | English (PDF, 741 KB) Spanish (PDF, 787 KB) |
Disclosure (PDF, 808 KB) |
| Vision Standard 0/0/75 | English (PDF, 742 KB) Spanish (PDF, 787 KB) |
Disclosure (PDF, 808 KB) |
| Vision Standard 0/15/120 | English (PDF, 743 KB) Spanish (PDF, 791 KB) |
Disclosure (PDF, 808 KB) |
| Vision Standard 0/15/130 | English (PDF, 743 KB) Spanish (PDF, 791 KB) |
Disclosure (PDF, 808 KB) |
| Vision Standard 0/25/100 | English (PDF, 742 KB) Spanish (PDF, 789 KB) |
Disclosure (PDF, 808 KB) |
| Vision Standard 10/0/100 | English (PDF, 742 KB) Spanish (PDF, 787 KB) |
Disclosure (PDF, 808 KB) |
2022 Materials Only Vision Plan
| Plan Name | Summary of Benefits | Disclosures |
|---|---|---|
| Vision Standard Materials only -/15/120 | English 242KB Spanish 256KB | Disclosure 380KB |
