Page 17 - SunWest EE Guide 09-19 Outside CA
P. 17

Vision Plan








         Anthem Blue Cross | Vision Plan
         Sun West 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                                       $10 Copay                           N/A
          - Materials                                         $25 Copay                           N/A
         Examination (Every 12 Months)                        No Charge                Up to $49 Reimbursement
         Lenses (Every 12 Months)
          - Single Vision                                     No Charge                Up to $35 Reimbursement
          - Bifocal                                           No Charge                Up to $49 Reimbursement
          - Trifocal                                          No Charge                Up to $74 Reimbursement
         Lens Enhancements
          - Transitions (Under Age 19)                        No Charge                      Not Covered
          - Standard Polycarbonate (Under Age 19)             No Charge                      Not Covered
          - Factory Scratch Coating                           No Charge                      Not Covered
         Frames (Every 24 Months)                     $130 Benefit, 20% Discount        Up to $50 Reimbursement
         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 $250 Reimbursement




            Finding a Vision Provider
            Go to www.anthem.com/ca. Refer to the “Blue View Vision” network.

            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
                         Laser Vision Correction: Discount offers on LASIK surgery and much more are available through
                         Anthem’s Special Offers program. Visit www.anthem.com/specialoffers for more information.

                         Continued Eyewear Savings: When obtaining eyewear from a Blue View Vision provider, you may
                         choose to upgrade your new eyeglass lenses at discounted costs.









                                                                                                   Employee Benefits   17
   12   13   14   15   16   17   18   19   20   21   22