Page 12 - 2019 Sharks Benefits V6.1

Vision Plan

Our vision plan is designed to allow employees the flexibility to choose in or out of network benefits.
Employees enrolled in the vision plan are always free to obtain vision care from the vision care provider
of their choice. Please note that using in network providers will typically save you money over using out
of network providers.

Website: http://www.anthem.com/ca/ http://www.kp.org

Benefits at a Glance

Kaiser Vision
Anthem Vision
(Stand Alone Plan) (Included in Kaiser Medical &
Vision Plan)
Network Non-Network Network
Plan Features
Benefits Benefits Benefits
Frequency of Service
Examination Every 12 Months Every 12 Months Every 12 Months

Lenses Every 12 Months Every 12 Months Every 12 Months

Frames Every 12 Months Every 12 Months Every 12 Months
Contact Lenses Every 12 Months Every 12 Months Every 12 Months

Annual Benefits
Examination $10 Up to $49* Covered in Full

Single Lenses $10 Up to $35 Covered in Full
Bifocal Lenses $10 Up to $49 Covered in Full

Trifocal Lenses $10 Up to $74 Covered in Full

$130*, then 15%
off any
Frames Up to $50* $130 allowance
remaining
balance
Contacts (Medically Necessary) Covered in Full $250* $130 allowance

Contacts (Elective) $130* $92* $130 allowance
Please Note

* The dollar amount listed under the benefits is the total reimbursement amount you will receive when
obtaining care from a non-network provider. You will first be required to pay the provider for care and
then submit a claim to Anthem Blue View for partial reimbursement, unless the provider will bill Anthem
Blue Cross directly. If you decide to see a provider that is not an Anthem Blue View provider, please
contact member services at (866) 723-0515.
** These percentages are based on standard Anthem Blue View allowance. Any amount in excess of the
Anthem Blue View allowance will be the responsibility of the plan participant. The Anthem Blue View
provider will review exact coverage’s and exclusions at the time examination is performed and eyewear
dispensed. The current allowance for frames under the Anthem Blue View is $130.
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