Page 29 - RTF.24 Employee Benefits

2021 Vision Benefits

Anthem Vision Plan

You have the option to enroll in our group vision plan. The benefits and your contributions are as
follows:

You are strongly Benefit In Network Out-of-Network
encouraged to use an in- Routine Eye Exam (once every 12 months) $20 copay then $42 Allowance
network provider to covered in full
maximize your benefits Eyeglass Frames (once every 24 months) $140 allowance $45 Allowance
then 20% off
and minimize your out- remaining balance
of-pocket cost. To see if Eyeglass Lenses (one pair every 12 months)
your provider is in the • Standard plastic single vision lenses $20 copay then $40 allowance
network click on • Standard plastic bifocal lenses covered in full $60 allowance
Provider Network • Stnadard plastic trifocal lenses $80 allowance
Eyeglass Lens Upgrades
• UV Coating $15
• Tint (Solid and Gradient)
$15
Payment to non- • Standard Polycarbonate $15 Discounts on lens
network providers will • lenses upgrades not
be based on the • Progressive Lenses 1 $0 available out-of-
Standard
•
Network fee schedule • Premium Tier 1 $26 network
$32
and could result in • Premium Tier 2 $38
•
Premium Tier 3
balance billing. • Standard Anti-Reflective Coating 2 $45
• Premium Tier 1 Anti-Reflective Coating 2 $57
• Premium Tier 2 Anti-Reflective Coating 2 $68
• Other Add-ons and Services 20% off retail price
Those who prefer Contact Lenses (once every 12 months)
contact lenses over • Elective Conventional Lenses $140 allowance $100 allowance
glasses may receive then 15% off
contact lenses instead of remaining balance

eyeglass lenses and • Elective Disposable Lenses $140 allowance $100 allowance
receive an allowance (no add’l discount)
towards the cost of a
supply of contact lenses. • Non-Elective Contact Lenses Covered in full $210 allowance

Contact Lenses Fitting and Follow UP
• Standard contact lens fitting Member cost up to
$55
• Premium contact lens fitting $10% off retail
(limitations apply – see certificate for details)

Coverage Election Monthly Salaries EE’s Hourly EE’s
Employee Only $1.90 $0.62 $0.31
Employee + Spouse $3.32 $1.30 $0.65
Employee + Children $3.60 $1.52 $0.76
Family $5.50 $2.24 $1.12

For additional plan information, please refer to the detailed plan description provided by the carrier.
In the event of a discrepancy, the carrier Pan Document shall prevail.