Page 16 - Veritone EE OOS Benefit Guide_2020

VISION PLAN

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

Anthem Blue Cross
Plan Name PPO

Network Name Blue View Vision Non-Network
Vision Benefits Additional In-Network Savings

Copay Eyeglass Lens Upgrades
- Examination $10 Copay N/A • Transition Lenses (Adults): $75 copay
- Materials $25 Copay N/A
• Standard Polycarbonate (Adults): $40 copay
Examination (Every 12 Months) No Charge Up to $49 Reimbursement • 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
•
Other Add-ons: 20% Off Retail Price
- Trifocal No Charge Up to $74 Reimbursement

Frames (Every 12 Months) $130 Benefit, then Up to $50 Reimbursement Additional Pair of Eyeglasses
20% Discount • Complete Pair: 40% off retail price
Contact Lenses (Every 12 Months) (in lieu of frames and lenses) • Eyeglass materials purchase separately: 20% off retail
price

- Cosmetic / Elective $130 Benefit Up to $92 Reimbursement Eyewear Accessories
- Medically Necessary No Charge Up to $250 Reimbursement
• Items such as non-prescription sunglasses, lens cleaning
Laser Vision Correction Discounts Apply Not Covered supplies, contact lens solutions, and eyeglass cases: 20%
off retail price
Finding a Vision Provider
Go to www.anthem.com/ca. Refer to the Blue View Vision network Contact Lens Fit and Follow-up
• Standard Contact Lens Fittings: Up to $55
Anthem’s network includes access to more than 44,000 providers and provider locations • Premium Contact Lens Fitting: 10% off retail price
including independent ophthalmologists and optometrists, as well as LensCrafters®, Target
Optical, Sears Optical, and JCPenney Optical .

16 EMPLOYEE BENEFITS