Page 11 - Humano EE Guide 06-20

Vision Plan

Anthem Blue Cross | Vision Plan
Humano 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 $20 Copay N/A
- Materials $20 Copay N/A
Examination (Every 12 Months) No Charge after Copay Up to $42 Reimbursement
Lenses (Every 12 Months)
- Single Vision No Charge after Copay Up to $40 Reimbursement
- Bifocal No Charge after Copay Up to $60 Reimbursement
- Trifocal No Charge after Copay Up to $80 Reimbursement
Frames (Every 24 Months) $130 Benefit, Up to $45 Reimbursement
then 20% Discount
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 $210 Reimbursement

Finding a Vision Provider
Go to www.anthem.com/ca or call (866) 723-0515. Refer to the “Blue View
Vision” network when prompted.

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
• Eyeglass Lens Upgrades: When obtaining eyewear from a network provider, you may choose to
upgrade your new eyeglass lenses at a discounted cost. Eyeglass lens copays will vary based on
the upgrade selected.
• Additional Pairs of Eyeglasses: Receive a 40% discount for a complete pair or a 20% discount for
eyeglass materials (purchased separately) from a network provider.
• Contact Lens Fit and Follow-up: A contact lens fitting and up to two follow-up visits are
available to you once you complete a comprehensive eye exam. A standard contact lens fitting is
available at a $55 copay. A premium contact lens fitting is available for a 10% discount to the
retail price.

Employee Benefits 11