Summary of Benefits 2023 - 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, 1.1 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	Disclosure
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	Disclosure
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 – 2024: for renewing groups only

Plan names	Summaries of Benefits	Disclosure
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

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