Page 16 - Veritone EE Guide 07-19

Anthem Blue Cross | Vision Plan
Veritone 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
Additional In-Network Savings
Copay
- Examination $10 Copay N/A Eyeglass Lens Upgrades
- Materials $25 Copay N/A · Transition Lenses (Adults): $75 copay
Examination (Every 12 Months) No Charge Up to $49 Reimbursement · Standard Polycarbonate (Adults): $40 copay
· Tint (Solid and Gradient): $15 copay
Lenses (Every 12 Months) · UV Coating: $15 copay
- Single Vision No Charge Up to $35 Reimbursement · Progressive Lenses: $65-$110 copay
- Bifocal No Charge Up to $49 Reimbursement · Anti-Reflective Coating: $45-$68 copay
- Trifocal No Charge Up to $74 Reimbursement · Other Add-ons: 20% Off Retail Price
Frames (Every 12 Months) $130 Benefit, then Up to $50 Reimbursement
20% Discount Additional Pair of Eyeglasses
· Complete Pair: 40% off retail price
Contact Lenses (Every 12 (in lieu of frames and lenses) · Eyeglass materials purchase separately: 20% off retail
Months) price
- Cosmetic / Elective $130 Benefit Up to $92 Reimbursement
- Medically Necessary No Charge Up to $250 Reimbursement Eyewear Accessories
· Items such as non-prescription sunglasses, lens
Laser Vision Correction Discounts Apply Not Covered cleaning supplies, contact lens solutions, and eyeglass
Finding a Vision Provider cases: 20% off retail price
Go to www.anthem.com/ca. Refer to the Blue View Vision network
Contact Lens Fit and Follow-up
Anthem’s network includes access to more than 44,000 providers and provider locations · Standard Contact Lens Fittings: Up to $55
including independent ophthalmologists and optometrists, as well as LensCrafters®, · Premium Contact Lens Fitting: 10% off retail price
Target Optical, Sears Optical, and JCPenney Optical .