Summary of Benefits 2023 - Vision

The following Summary of Benefits (SOB) 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)

2023 Vision Summary of Benefits

Vision 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 0/0/150 English (PDF, 742 KB)    Spanish (PDF, 790 KB) Disclosure (PDF, 808 KB)
Vision Deluxe 0/25/130 English (PDF, 742 KB)    Spanish (PDF, 787 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 Contacts 15/25/150/150 English (PDF, 743 KB)    Spanish (PDF, 791 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 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 0/0/150 English (PDF, 740 KB)    Spanish (PDF, 788 KB) Disclosure (PDF, 808 KB)
Vision Plus 0/25/130 English (PDF, 742 KB)    Spanish (PDF, 791 KB) Disclosure (PDF, 808 KB)
Vision Plus 10/25/120 English (PDF, 743 KB)    Spanish (PDF, 789 KB) Disclosure (PDF, 808 KB)
Vision Plus 10/25/130 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 10/25/130/130 English (PDF, 743 KB)    Spanish (PDF, 792 KB) Disclosure (PDF, 808 KB)
Vision Plus with Contact Lens and Fitting 10/25/150/150 English (PDF, 743 KB)    Spanish (PDF, 792 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 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 0/0/150 English (PDF, 742 KB)    Spanish (PDF, 788 KB) Disclosure (PDF, 808 KB)
Vision Standard 0/25/130 English (PDF, 743 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)
Vision Standard with Contacts 0/0/150/150 English (PDF, 742 KB)    Spanish (PDF, 790 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 with Contact Lens and Fitting 10/25/150/150 English (PDF, 740 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 Plus 10/0/100 English (PDF, 740 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 10/0/100 English (PDF, 742 KB)    
Spanish (PDF, 787 KB)		 Disclosure (PDF, 808 KB)
Vision Standard 0/25/100 English (PDF, 742 KB)    
Spanish (PDF, 789 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 Plus 0/25/120 English (PDF, 742 KB)    
Spanish (PDF, 789 KB)		 Disclosure (PDF, 808 KB)
Vision Plus 0/15/130 English (PDF, 740 KB)    
Spanish (PDF, 780 KB)		 Disclosure (PDF, 808 KB)
Vision Deluxe 0/15/130 English (PDF, 742 KB)    
Spanish (PDF, 790 KB)		 Disclosure (PDF, 808 KB)
Vision Standard 0/0/100 English (PDF, 741 KB)    
Spanish (PDF, 787 KB)		 Disclosure (PDF, 808 KB)

2023 Materials Only Vision Plan

Plan name Summary of Benefits Disclosures
Vision Standard Materials only -/15/120  English (PDF, 242 KB)  
Spanish (PDF, 256 KB)		 Disclosure (PDF, 380 KB)

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