Page 24 - Centennial Enrollment

Vision Benefit Coverage—Anthem

In-Network Out-of-Network

Eye Exam $10 copay Up to $25 reimbursement

Lenses

Single vision $10 copay Up to $20 reimbursement

Bifocal $10 copay Up to $40 reimbursement

Trifocal $10 copay Up to $65 reimbursement

Lenticular $10 copay Up to $65 reimbursement

Frames $150 allowance, additional 20% Up to $65 reimbursement
off balance
Contact Lenses

Elective $150 allowance, additional 15% Up to $105 reimbursement
off balance

Necessary $0 copay Up to $200 reimbursement

Vision—Frequency

Exams 12 months

Lenses 12 months

Frames 24 months

Contact lenses (in lieu of standard lenses and frames) 12 months 23