Page 17 - SunWest EE Guide 09-19 CA

Vision Plan

Anthem Blue Cross | Vision Plan
Sun West provides vision coverage through Anthem Blue Cross. You can see an Anthem Blue Cross in-network
provider or an out-of-network provider, however, your costs will be lower if you visit an in-network provider. If you
visit an in-network provider you will be responsible for a copayment at the time of your service. If you receive
services from an out-of-network doctor, you will pay all costs at the time of service and submit a claim for
reimbursement.

Anthem Blue Cross
Plan Name PPO
Network Name Blue View Vision Non-Network

Vision Benefits
Copay
- Examination $10 Copay N/A
- Materials $25 Copay N/A
Examination (Every 12 Months) No Charge Up to $49 Reimbursement
Lenses (Every 12 Months)
- Single Vision No Charge Up to $35 Reimbursement
- Bifocal No Charge Up to $49 Reimbursement
- Trifocal No Charge Up to $74 Reimbursement
Lens Enhancements
- Transitions (Under Age 19) No Charge Not Covered
- Standard Polycarbonate (Under Age 19) No Charge Not Covered
- Factory Scratch Coating No Charge Not Covered
Frames (Every 24 Months) $130 Benefit, 20% Discount Up to $50 Reimbursement
Contact Lenses (Every 12 Months) (in lieu of frames and lenses)
- Cosmetic / Elective $130 Benefit Up to $92 Reimbursement
- Medically Necessary No Charge Up to $250 Reimbursement

Finding a Vision Provider
Go to www.anthem.com/ca. Refer to the “Blue View Vision” network.

Anthem’s network includes access to more than 44,000 providers and
provider locations including independent ophthalmologists and
optometrists, as well as LensCrafters®, Target Optical, Sears Optical,
JCPenney Optical and most Pearle Vision retail stores.

Additional Discounts Available
Laser Vision Correction: Discount offers on LASIK surgery and much more are available through
Anthem’s Special Offers program. Visit www.anthem.com/specialoffers for more information.

Continued Eyewear Savings: When obtaining eyewear from a Blue View Vision provider, you may
choose to upgrade your new eyeglass lenses at discounted costs.

Employee Benefits 17