Summary of Benefits 2027 – 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, 1 MB)

2027 Vision Summary of Benefits

Vision plan name	Summary of Benefits	Disclosures
Vision Deluxe 0/0/130	English (PDF, 221 KB) Spanish (Coming soon)	Disclosure (PDF, 808 KB)
Vision Deluxe 0/0/150	English (PDF, 221 KB) Spanish (Coming soon)	Disclosure (PDF, 808 KB)
Vision Deluxe 0/25/130	English (PDF, 222 KB) Spanish (Coming soon)	Disclosure (PDF, 808 KB)
Vision Deluxe 10/25/130	English (PDF, 222 KB) Spanish (Coming soon)	Disclosure (PDF, 808 KB)
Vision Deluxe 10/25/150	English (PDF, 221 KB) Spanish (Coming soon)	Disclosure (PDF, 808 KB)
Vision Deluxe 10/25/150/150	English (PDF, 222 KB) Spanish (Coming soon)	Disclosure (PDF, 808 KB)
Vision Deluxe 15/25/130	English (PDF, 222 KB) Spanish (Coming soon)	Disclosure (PDF, 808 KB)
Vision Deluxe 15/25/150	English (PDF, 221 KB) Spanish (Coming soon)	Disclosure (PDF, 808 KB)
Vision Deluxe with Contact Lens and Fitting 10/25/150/150	English (PDF, 222 KB) Spanish (Coming soon)	Disclosure (PDF, 808 KB)
Vision Deluxe with Contacts 0/0/150/150	English (PDF, 221 KB) Spanish (Coming soon)	Disclosure (PDF, 808 KB)
Vision Deluxe with Contacts 15/25/150/150	English (PDF, 222 KB) Spanish (Coming soon)	Disclosure (PDF, 808 KB)
Vision Plus 0/0/130	English (PDF, 221 KB) Spanish (Coming soon)	Disclosure (PDF, 808 KB)
Vision Plus 0/0/150	English (PDF, 221 KB) Spanish (Coming soon)	Disclosure (PDF, 808 KB)
Vision Plus 0/25/130	English (PDF, 222 KB) Spanish (Coming soon)	Disclosure (PDF, 808 KB)
Vision Plus 10/25/130	English (PDF, 222 KB) Spanish (Coming soon)	Disclosure (PDF, 808 KB)
Vision Plus 10/25/150	English (PDF, 222 KB) Spanish (Coming soon)	Disclosure (PDF, 808 KB)
Vision Plus 15/25/130	English (PDF, 222 KB) Spanish (Coming soon)	Disclosure (PDF, 808 KB)
Vision Plus 15/25/150	English (PDF, 222 KB) Spanish (Coming soon)	Disclosure (PDF, 808 KB)
Vision Plus with Contact Lens and Fitting 10/25/130/130	English (PDF, 222 KB) Spanish (Coming soon)	Disclosure (PDF, 808 KB)
Vision Plus with Contact Lens and Fitting 10/25/150/150	English (PDF, 222 KB) Spanish (Coming soon)	Disclosure (PDF, 808 KB)
Vision Plus with Contacts 0/0/150/150	English (PDF, 222 KB) Spanish (Coming soon)	Disclosure (PDF, 808 KB)
Vision Plus with Contacts 15/25/150/150	English (PDF, 222 KB) Spanish (Coming soon)	Disclosure (PDF, 808 KB)
Eye Exam Only	English (PDF, 208 KB) Spanish (Coming soon)	Disclosure (PDF, 808 KB)

Voluntary Vision plans	Summary of Benefits	Disclosures
Vision Deluxe Voluntary 10/25/130	English (PDF, 222 KB) Spanish (Coming soon)	Disclosure (PDF, 808 KB)
Vision Deluxe Voluntary 15/25/150	English (PDF, 221 KB) Spanish (Coming soon)	Disclosure (PDF, 808 KB)
Vision Plus Voluntary 10/25/130	English (PDF, 222 KB) Spanish (Coming soon)	Disclosure (PDF, 808 KB)
Vision Plus Voluntary 15/25/130	English (PDF, 222 KB) Spanish (Coming soon)	Disclosure (PDF, 808 KB)

Not Marketed Vision Plans	Summary of Benefits	Disclosures
Vision Deluxe 0/0/120	English (PDF, 221 KB) Spanish (Coming soon)	Disclosure (PDF, 808 KB)
Vision Deluxe 0/15/130	English (PDF, 222 KB) Spanish (Coming soon)	Disclosure (PDF, 808 KB)
Vision Deluxe 10/25/120	English (PDF, 222 KB) Spanish (Coming soon)	Disclosure (PDF, 808 KB)
Vision Deluxe 15/25/120	English (PDF, 222 KB) Spanish (Coming soon)	Disclosure (PDF, 808 KB)
Vision Plus 0/0/120	English (PDF, 221 KB) Spanish (Coming soon)	Disclosure (PDF, 808 KB)
Vision Plus 0/15/130	English (PDF, 222 KB) Spanish (Coming soon)	Disclosure (PDF, 808 KB)
Vision Plus 10/25/120	English (PDF, 222 KB) Spanish (Coming soon)	Disclosure (PDF, 808 KB)
Vision Plus 15/25/120	English (PDF, 222 KB) Spanish (Coming soon)	Disclosure (PDF, 808 KB)
Vision Plus Voluntary 15/25/120	English (PDF, 222 KB) Spanish (Coming soon)	Disclosure (PDF, 808 KB)
Vision Standard 10/25/120	English (PDF, 222 KB) Spanish (Coming soon)	Disclosure (PDF, 808 KB)
Vision Standard 10/25/150	English (PDF, 222 KB) Spanish (Coming soon)	Disclosure (PDF, 808 KB)
Vision Standard 0/0/100	English (PDF, 222 KB) Spanish (Coming soon)	Disclosure (PDF, 808 KB)
Vision Standard 0/0/120	English (PDF, 222 KB) Spanish (Coming soon)	Disclosure (PDF, 808 KB)
Vision Standard 0/0/130	English (PDF, 222 KB) Spanish (Coming soon)	Disclosure (PDF, 808 KB)
Vision Standard 0/0/150	English (PDF, 222 KB) Spanish (Coming soon)	Disclosure (PDF, 808 KB)
Vision Standard 0/0/75	English (PDF, 222 KB) Spanish (Coming soon)	Disclosure (PDF, 808 KB)
Vision Standard 0/25/100	English (PDF, 222 KB) Spanish (Coming soon)	Disclosure (PDF, 808 KB)
Vision Standard 0/25/130	English (PDF, 222 KB) Spanish (Coming soon)	Disclosure (PDF, 808 KB)
Vision Standard 15/25/120	English (PDF, 222 KB) Spanish (Coming soon)	Disclosure (PDF, 808 KB)
Vision Standard 15/25/130	English (PDF, 222 KB) Spanish (Coming soon)	Disclosure (PDF, 808 KB)
Vision Standard 15/25/150	English (PDF, 222 KB) Spanish (Coming soon)	Disclosure (PDF, 808 KB)
Vision Standard Voluntary 10/25/130	English (PDF, 222 KB) Spanish (Coming soon)	Disclosure (PDF, 808 KB)
Vision Standard Voluntary 15/25/120	English (PDF, 222 KB) Spanish (Coming soon)	Disclosure (PDF, 808 KB)
Vision Standard with Contact Lens and Fitting 10/25/150/150	English (PDF, 222 KB) Spanish (Coming soon)	Disclosure (PDF, 808 KB)
Vision Standard with Contacts 0/0/150/150	English (PDF, 222 KB) Spanish (Coming soon)	Disclosure (PDF, 808 KB)
Vision Standard with Contacts 15/25/150/150	English (PDF, 222 KB) Spanish (Coming soon)	Disclosure (PDF, 808 KB)

2027 Materials Only Vision Plan

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

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