Page 15 - CHSI Benefit Guide 2019-2020

Vision Benefits

Anthem Blue Cross | PPO Vision Plan
The Anthem Blue Cross 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 Blue View Vision.

Anthem Blue Cross
Blue View Vision PPO Plan
Network Non-Network
Vision Benefits

Copay
- Examination $10 Copay N/A
- Materials $20 Copay N/A
Examination (Every 12 Months) $10 Copay Up to $49 allowance
Lenses (Every 12 Months)
− Single Vision $20 Copay $35 Reimbursement
− Bifocal $20 Copay $49 Reimbursement
− Trifocal $20 Copay $74 Reimbursement

Frames (Every 24 Months) $130 Allowance + 20% off Up to $50 allowance
Contact Lenses (Every 12 Months) In Lieu of Frames and Lenses
− Cosmetic / Elective $130 Allowance $92 Reimbursement
− Medically Necessary 100% $250 Reimbursement

Finding In-Network Vision Providers

Go to www.anthem.com/ca.com or call (866) 723-0515 and refer to the Blue View Vision, Plan BV5B network
when prompted.

15