Page 11 - JFSLA - Benefits Guide 2018-2019 (5.29.18)

Benefits

Vision Insurance

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.

Carrier Anthem
Plan Name Blue View 12C PPO Vision Plan
Network Name Blue View Vision Non-Network

Vision Benefits
Copay
- Examination $25 Copay N/A
- Materials $15 Copay N/A

Examination 100% $49 Reimbursement
Lenses
- Single Vision $15 Copay then 100% $35 Reimbursement
- Bifocal $15 Copay then 100% $49 Reimbursement
- Trifocal $15 Copay then 100% $74 Reimbursement
- Lenticular 80% of Retail Not Covered
- Standard Progressive $65 Copay $49 Reimbursement
- Premium Progressive $85—$110 Copay $49 Reimbursement

- UV Treatment $15 Copay Not Covered
- Tint (Solid and Gradient) $15 Copay Not Covered
- Standard Anti-Reflective $45 Copay Not Covered
- Polarized 80% of Retail Not Covered

Frames $130 Allowance $50 Reimbursement
Additional 20% off Balance
Contact Lenses (in lieu of frames/lenses)
- Cosmetic / Elective $130 Allowance $92 Reimbursement
Additional 15% off Balance
- Medically Necessary 100% $250 Reimbursement
Frequency
- Examination Every 12 Months
- Lenses Every 24 Months
- Frames Every 24 Months
- Contact Lenses Every 24 Months

Finding a Vision Provider
www.anthem.com/ca: From the Anthem website, scroll down and click on the blue link labeled “Find a
doctor>.” Next, under “Search as Guest?” click on “Search by Selecting a Plan or Network.” Under “What type of
care are you searching for?” select “Vision.” Under “What state do you want to search in?” select your state of
residence, and under Select a plan/network, select the network listed under “Vision.” Refer to the applicable
network names (shown above and also on page 5 of this guide) when you are prompted to select a plan. You
may search by name under “Whose name is:”

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