Page 17 - Open Enrollment Guide Sample
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Vision
Vision beneits are essential towards maintaining your overall health and Bi-Weekly Vision Contributions
well-being, which is why we are proud to offer vision coverage through Team member $2.13
Anthem Blue View Vision utilizing the EyeMed Insight network. The Team member + Spouse $3.73
Insight network includes convenient retail locations, many with evening Team member + $4.05
and weekend hours, including LensCrafters, Sears Optical, Target Optical, Child(ren)*
JCPenney Optical and most Pearle Vision locations. For additional Family** $6.18
participating providers visit www.anthem.com or call (877) 635-6403. * Team member + Child(ren) includes
the Team member plus any number of
children
Your vision beneit may be applied toward any eye exam, available ** Family includes the Team member, a
frame, or brand of contact lenses that it your lifestyle. Please refer to Spouse, and any number of children
[Web Address] for a more detailed beneit summary. You and your eligible dependents to
age 26 are eligible to participate in
What It Covers the Vision insurance program.
In-network Out-of-network
Covered Services
Beneit
Vision Examination (once every 12 months) $10 copay Up to $42
Standard Contact Lenses Fit and Follow-Up (once $55 allowance Not Available
every 12 months)
Eyeglass Frames (once every 24 months) $125 allowance, 20% off any remaining Up to $45
balance
Standard Lenses (once every 12 months)
Single Vision/Bifocal/ Trifocal $25 copay Up to: $40/$60/$80
Eyeglass Lens Enhancements
Transitions Lenses and Standard Polycarbonate— $25 copay Not Available
Children under age 19
Eyeglass Lens Upgrades (Materials Copay Applies)
Transitions Lenses—Adults $75 Not Available
Standard Polycarbonate—Adults $40 Not Available
Tint (Solid and Gradient) and UV Coating $15 Not Available
Progressive Lenses $65—$110 Not Available
Anti-Relective Coating $45—$68 Not Available
Contact Lenses
Elective Conventional Lenses $125 allowance, then 15% off any $100 allowance
remaining balance
Elective Disposable Lenses $125 allowance $105 allowance
Non-Elective Contact Lenses Covered in Full $200 allowance
Laser Vision Correction Surgery
LASIK refractive surgery Go to anthem.com/special offers and Not Available
select vision care
2016 Open Enrollment
Vision
Vision beneits are essential towards maintaining your overall health and Bi-Weekly Vision Contributions
well-being, which is why we are proud to offer vision coverage through Team member $2.13
Anthem Blue View Vision utilizing the EyeMed Insight network. The Team member + Spouse $3.73
Insight network includes convenient retail locations, many with evening Team member + $4.05
and weekend hours, including LensCrafters, Sears Optical, Target Optical, Child(ren)*
JCPenney Optical and most Pearle Vision locations. For additional Family** $6.18
participating providers visit www.anthem.com or call (877) 635-6403. * Team member + Child(ren) includes
the Team member plus any number of
children
Your vision beneit may be applied toward any eye exam, available ** Family includes the Team member, a
frame, or brand of contact lenses that it your lifestyle. Please refer to Spouse, and any number of children
[Web Address] for a more detailed beneit summary. You and your eligible dependents to
age 26 are eligible to participate in
What It Covers the Vision insurance program.
In-network Out-of-network
Covered Services
Beneit
Vision Examination (once every 12 months) $10 copay Up to $42
Standard Contact Lenses Fit and Follow-Up (once $55 allowance Not Available
every 12 months)
Eyeglass Frames (once every 24 months) $125 allowance, 20% off any remaining Up to $45
balance
Standard Lenses (once every 12 months)
Single Vision/Bifocal/ Trifocal $25 copay Up to: $40/$60/$80
Eyeglass Lens Enhancements
Transitions Lenses and Standard Polycarbonate— $25 copay Not Available
Children under age 19
Eyeglass Lens Upgrades (Materials Copay Applies)
Transitions Lenses—Adults $75 Not Available
Standard Polycarbonate—Adults $40 Not Available
Tint (Solid and Gradient) and UV Coating $15 Not Available
Progressive Lenses $65—$110 Not Available
Anti-Relective Coating $45—$68 Not Available
Contact Lenses
Elective Conventional Lenses $125 allowance, then 15% off any $100 allowance
remaining balance
Elective Disposable Lenses $125 allowance $105 allowance
Non-Elective Contact Lenses Covered in Full $200 allowance
Laser Vision Correction Surgery
LASIK refractive surgery Go to anthem.com/special offers and Not Available
select vision care
2016 Open Enrollment
