Page 10 - FINAL Crane Country Day School 2017-18 Benefits Guide

Vision Plan 10

Anthem | PPO Vision Plan

The Anthem vision plan provides professional vision care and high quality lenses and frames through a broad
network of optical specialists. You will receive richer benefits if you utilize a network provider. If you utilize a
non-network provider, you will be responsible to pay all charges at the time of your appointment and will be
required to file an itemized claim with Anthem.

Anthem PPO Vision BV 5B
In-Network Out-of-Network

You Pay You Pay
Eye Exams
Copay $10 copay Reimburse up to $49

Glasses
Frames $130 allowance, then 20% off Reimburse up to $50
any remaining balance
Lenses
Single Vision $20 copay Reimburse up to $35
Bifocal $20 copay Reimburse up to $49
Trifocal $20 copay Reimburse up to $74
Progressive $65 copay (standard) Not covered

Contact Lenses (in lieu of glasses)
Medically Necessary Covered in full Reimburse up to $250

Elective $130 allowance, then 15% off Reimburse up to $92
any remaining balance

Frequency
Eye Exam Once every 12 months

Frames Once every 24 months

Lenses Once every 12 months

Contact Lenses Once every 12 months

* Footnote: This is only a summary of benefits. Please refer to plan documents for full details.

To Find an Anthem Provider: www.anthem.com/ca