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2023 Vision Summary of Benefits

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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 Plan Name Summary of Benefits Disclosure
Vision Deluxe 0/0/120 English 740KB    Spanish 787KB Disclosure 808KB
Vision Deluxe 0/0/130 English 740KB    Spanish 787KB Disclosure 808KB
Vision Deluxe 0/0/150 English 742KB    Spanish 790KB Disclosure 808KB
Vision Deluxe 0/25/130 English 742KB    Spanish 787KB Disclosure 808KB
Vision Deluxe 10/25/120 English 742KB    Spanish 789KB Disclosure 808KB
Vision Deluxe 10/25/150 English 742KB    Spanish 790KB Disclosure 808KB
Vision Deluxe 15/25/120 English 742KB    Spanish 789KB Disclosure 808KB
Vision Deluxe 15/25/130 English 742KB    Spanish 790KB Disclosure  808KB
Vision Deluxe 15/25/150 English 743KB    Spanish 790KB Disclosure 808KB
Vision Deluxe with Contacts 0/0/150/150 English 742KB    Spanish 788KB Disclosure 808KB
Vision Deluxe with Contacts 15/25/150/150 English 743KB    Spanish 791KB Disclosure 808KB
Vision Deluxe with Contact Lens and Fitting 10/25/150/150 English 742KB    Spanish 791KB Disclosure 808KB
Vision Plus 0/0/120 English 740KB    Spanish 787KB Disclosure 808KB
Vision Plus 0/0/130 English 740KB    Spanish 787KB Disclosure 808KB
Vision Plus 0/0/150 English 740KB    Spanish 788KB Disclosure 808KB
Vision Plus 0/25/130 English 742KB    Spanish 791KB Disclosure 808KB
Vision Plus 10/25/120 English 743KB    Spanish 789KB Disclosure 808KB
Vision Plus 10/25/130 English 743KB    Spanish 789KB Disclosure 808KB
Vision Plus 10/25/150 English 743KB    Spanish 791KB Disclosure 808KB
Vision Plus 15/25/120 English 743KB    Spanish 789KB Disclosure 808KB
Vision Plus 15/25/130 English 743KB    Spanish 791KB Disclosure 808KB
Vision Plus 15/25/150 English 743KB    Spanish 791KB Disclosure 808KB
Vision Plus with Contacts 0/0/150/150 English 740KB    Spanish 788KB Disclosure 808KB
Vision Plus with Contacts 15/25/150/150 English 740KB    Spanish 791KB Disclosure 808KB
Vision Plus with Contact Lens and Fitting 10/25/130/130 English 743KB    Spanish 792KB Disclosure 808KB
Vision Plus with Contact Lens and Fitting 10/25/150/150 English 743KB    Spanish 792KB Disclosure 808KB
Vision Standard 10/25/120 English 743KB    Spanish 780KB Disclosure 808KB
Vision Standard 10/25/150 English 740KB    Spanish 791KB Disclosure 808KB
Vision Standard 0/0/120 English 742KB    Spanish 788KB Disclosure 808KB
Vision Standard 0/0/130 English 740KB    Spanish 787KB Disclosure 808KB
Vision Standard 0/0/150 English 742KB    Spanish 788KB Disclosure 808KB
Vision Standard 0/25/130 English 743KB    Spanish 791KB Disclosure 808KB
Vision Standard 15/25/120 English 743KB    Spanish 791KB Disclosure 808KB
Vision Standard 15/25/130 English 743KB    Spanish 791KB Disclosure 808KB
Vision Standard 15/25/150 English 743KB    Spanish 791KB Disclosure 808KB
Vision Standard with Contacts 0/0/150/150 English 742KB    Spanish 790KB Disclosure 808KB
Vision Standard with Contacts 15/25/150/150 English 743KB    Spanish 791KB Disclosure 808KB
Vision Standard with Contact Lens and Fitting 10/25/150/150 English 740KB    Spanish 791KB Disclosure 808KB
Eye Exam Only English 728KB    Spanish 763KB Disclosure 808KB

 

Voluntary Vision Plans Summary of Benefits Disclosures
Vision Deluxe Voluntary 10/25/130 English 742KB    Spanish 791KB Disclosure 808KB
Vision Deluxe Voluntary 15/25/150 English 742KB    Spanish 790KB Disclosure 808KB
Vision Plus Voluntary 10/25/130 English 743KB    Spanish 791KB Disclosure 808KB
Vision Plus Voluntary 15/25/120 English 743KB    Spanish 790KB Disclosure 808KB
Vision Standard Voluntary 10/25/130 English 743KB    Spanish 791KB Disclosure 808KB
Vision Standard Voluntary 15/25/120 English 743KB    Spanish 790KB Disclosure 808KB

 

Not Marketed Vision Plans Summary of Benefits Disclosure
Vision Plus 10/0/100 English 740KB    Spanish 787KB Disclosure 808KB
Vision Standard 0/0/75 English 742KB    Spanish 787KB Disclosure 808KB
Vision Standard 10/0/100 English 742KB    Spanish 787KB Disclosure 808KB
Vision Standard 0/25/100 English 742KB    Spanish 789KB Disclosure 808KB
Vision Standard 0/15/120 English 743KB    Spanish 791KB Disclosure 808KB
Vision Standard 0/15/130 English 743KB    Spanish 791KB Disclosure 808KB
Vision Plus 0/25/120 English 742KB    Spanish 789KB Disclosure 808KB
Vision Plus 0/15/130 English 740KB    Spanish 780KB Disclosure 808KB
Vision Deluxe 0/15/130 English 742KB    Spanish 790KB Disclosure 808KB
Vision Standard 0/0/100 English 741KB    Spanish 787KB Disclosure 808KB
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Plan Name Summary of Benefits Disclosures
Vision Standard Materials only -/15/120 

English 242KB  Spanish 256KB

 Disclosure 380KB

 

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    Chico, CA 95927-2540

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