January 2020 Vision Benefit Summaries Small Businesses (1 to 100)

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Benefit Summaries

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

How to read plan names: Eye exam copayment/materials copayment/frame allowance. 'Plus' plans include additional benefits for contact lens materials and fitting.

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Plan Name	Benefit summaries	Disclosures
Basic Vision 0/0/120	English Spanish	English
Basic Vision 0/0/150	English Spanish	English
Basic Vision Plus 0/0/150/120	English Spanish	English
Basic Vision 10/25/120	English Spanish	English
Basic Vision 10/25/150	English Spanish	English
Basic Vision Plus 10/25/150/120	English Spanish	English
Basic Vision Voluntary 10/25/120	English Spanish	English

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Plan Name	Benefit summaries	Disclosures
Preferred Vision 0/0/120	English Spanish	English
Preferred Vision 0/0/150	English Spanish	English
Preferred Vision Plus 0/0/150/120	English Spanish	English
Preferred Vision 10/25/120	English Spanish	English
Preferred Vision 10/25/150	English Spanish	English
Preferred Vision Plus 10/25/150/120	English Spanish	English
Preferred Vision Voluntary 10/25/120	English Spanish	English

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Plan Name	Benefit summaries	Disclosures
Ultimate Vision 0/0/120	English Spanish	English
Ultimate Vision 0/0/150	English Spanish	English
Ultimate Vision Plus 0/0/150/120	English Spanish	English
Ultimate Vision 10/25/120	English Spanish	English
Ultimate Vision 10/25/150	English Spanish	English
Ultimate Vision Plus 10/25/150/120	English Spanish	English
Ultimate Vision Voluntary 10/25/150	English Spanish	English

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Plan Name	Benefit summaries	Disclosures
Ultimate Vision Plus for Small Business 15/25/150/120	English Spanish	English
Ultimate Vision for Small Business 15/25/150	English Spanish	English
Ultimate Vision Voluntary for Small Business 15/25/150	English Spanish	English
Ultimate Vision for Small Business 15/25/120	English Spanish	English
Preferred Vision Plus for Small Business 15/25/150/120	English Spanish	English
Preferred Vision for Small Business 15/25/150	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
Basic Vision Voluntary for Small Business 15/25/120	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 15/25/150/120	English Spanish	English