Page 16 - Optima Tax EE Guide 01-20 AZ

Vision Plan

Anthem | Vision Plan
Optima Tax Relief provides vision coverage through Anthem. You can see an Anthem 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 copay 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
Plan Name PPO

Network Name Blue View Vision Non-Network
Vision Benefits
Copay
- Examination $15 Copay N/A
- Materials $25 Copay N/A
Examination (Every 12 Months) No Charge Up to $42 Reimbursement
Lenses (Every 12 Months)
- Single Vision No Charge Up to $40 Reimbursement
- Bifocal No Charge Up to $60 Reimbursement
- Trifocal No Charge Up to $80 Reimbursement
Eyeglass Lens Enhancements
- Transitions Lenses No Charge No allowance when obtained
(for a child under age 19) out-of-network
- Standard polycarbonate No Charge
(for a child under age 19)
- Factory scratch coating No Charge
Frames (Every 24 Months) $130 Benefit Up to $45 Reimbursement
Contact Lenses (Every 12 Months) (in lieu of frames and lenses)
- Cosmetic / Elective $130 Benefit Up to $105 Reimbursement
- Medically Necessary No Charge Up to $210 Reimbursement
Non-Prescription Sunglasses 20% discount off retail price Not Covered

Finding a Vision Provider
Visit www.anthem.com/ca.
Click Find a Doctor > You may log in or search as a Guest > If
searching as a Guest, refer to the following Plan/Network:
• Blue View Vision

Anthem’s network includes access to more than 29,000 eyecare
practitioners nationwide including independent ophthalmologists
and optometrists, as well as Walmart, LensCrafters, Site for Sore
Eyes, For Eyes Optical, and Target Optical retail stores.

16 Employee Benefits