Summary of Benefits 2022 - Vision

Summary of Benefits

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

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

Basic plans

Plan names	Summaries of Benefits	Disclosures
Basic Vision for Small Business 0/0/120	English Spanish	English
Basic Vision for Small Business 0/0/150	English Spanish	English
Basic Vision for Small Business 10/25/120	English Spanish	English
Basic Vision for Small Business 10/25/150	English Spanish	English
Basic Vision Plus for Small Business 0/0/150/150	English Spanish	English
Basic Vision Plus for Small Business 10/25/150/150	English Spanish	English
Basic Vision Voluntary for Small Business 10/25/120	English Spanish	English

Preferred plans

Plan names	Summaries of Benefits	Disclosures
Preferred Vision for Small Business 0/0/120	English Spanish	English
Preferred Vision for Small Business 0/0/150	English Spanish	English
Preferred Vision for Small Business 10/25/120	English Spanish	English
Preferred Vision for Small Business 10/25/150	English Spanish	English
Preferred Vision Plus for Small Business 0/0/150/150	English Spanish	English
Preferred Vision Plus for Small Business 10/25/150/150	English Spanish	English
Preferred Vision Voluntary for Small Business 10/25/120	English Spanish	English

Ultimate plans

Plan names	Summaries of Benefits	Disclosures
Ultimate Vision for Small Business 0/0/120	English Spanish	English
Ultimate Vision for Small Business 0/0/150	English Spanish	English
Ultimate Vision for Small Business 10/25/120	English Spanish	English
Ultimate Vision for Small Business 10/25/150	English Spanish	English
Ultimate Vision Plus for Small Business 0/0/150/150	English Spanish	English
Ultimate Vision Plus for Small Business 10/25/150/150	English Spanish	English
Ultimate Vision Voluntary for Small Business 10/25/150	English Spanish	English

Closed Vision plans – 2022: for renewing groups only

Plan names	Summaries of Benefits	Disclosures
Ultimate Vision for Small Business 15/25/120	English Spanish	English
Ultimate Vision Plus for Small Business 15/25/150/150	English Spanish	English
Ultimate Vision Voluntary for Small Business 15/25/150	English Spanish	English
Ultimate Vision for Small Business 15/25/150	English Spanish	English
Preferred Vision Plus for Small Business 15/25/150/150	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
Preferred Vision for Small Business 15/25/150	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 15/25/150/150	English Spanish	English
Basic Vision Voluntary for Small Business 15/25/120	English Spanish	English

All rights reserved. California Physicians’ Service DBA Blue Shield of California is an independent member of the Blue Shield Association. Health insurance products are offered by Blue Shield of California Life & Health Insurance Company. Health plans are offered by Blue Shield of California.