VISION INSURANCE



ANTHEM BLUE CROSS
& BLUE SHIELD




The CHEIBA Trust and the CHEIBA Trust Members are pleased to offer you a comprehensive managed vision
care program. Anthem Blue View Vision offers a market-leading network with over 30,000 doctors across
the nation, as well as the Anthem Whole Health Connection. This program clinically integrates vision with
our health plan to allow the most comprehensive care for our members.



Anthem Blue View Vision Program

Your vision benefit option is separated into three components:

1. Vision Exam Only Benefit - your enrollment in any of the CHEIBA medical plans will include coverage
for a routine eye exam (once every 12 months) through the Blue View Vision Network of providers.
Your health plan rates include the premium for this benefit, and the cost may be shared between you
and your employer.
2. Vision Materials Only Benefit - if you are enrolled in a CHEIBA medical plan, you can complement
your vision coverage by electing this Voluntary eyewear materials and lens treatment option.
3. Full Service Vision Benefit - employees who are not enrolled in a CHEIBA medical plan, but would like
vision coverage can elect the Voluntary full-service (exam and materials) vision coverage.

How Anthem Blue View Vision Works:

STEP ONE:
To obtain vision care services, call your Anthem Blue View Vision provider to make an
appointment. To locate an Anthem Blue View Vision network provider, call Customer
Service at 1-866-723-0515, visit www.anthem.com/ or contact your Human
Resources/Benefit Office.

STEP TWO:
When making an appointment:
Identify yourself as an Anthem Blue View Vision member









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VISION INSURANCE

STEP THREE:
When you arrive at your appointment, present your ID card to the office. The Anthem
Blue View Vision provider will verify eligibility and benefits via their internal system. Once
your eye exam is completed and a determination is made whether eyewear is necessary,
you can select eyeglasses or contacts at the office. Keep in mind you have the option to
purchase your materials (eyeglasses/contacts) at any in-network providers office,
including retail locations such as Sears Optical, Pearle Vision, JC Penney Optical, Target
Optical and LensCrafters. The Anthem Blue View network provider will calculate
applicable discounts and itemize any out-of-pocket expenses including copays, non-
covered lens enhancements, additional materials and/or overages. The balance must be
paid in full at the time of service.

How To Find a Provider:

With over 32,000 doctors at more than 26,000 locations nationwide, with independent
doctors, convenient retails stores and 1-800-CONTACTS - all in network - the Blue View
Vision provider network makes it easy for you and your family to take care of your vision
needs.

To search for a network provider, visit www.anthem.com and:




Select: Find a Doctor

 Select: Search by Selecting Plan or Network

 Select: State

Select a plan/network: Blue View Vision

Members can search for providers by name or location. Once you have entered the standard search
procedures, you can search for a provider offering materials by clicking on the show more options link and
selecting “materials (frames, lenses, contacts)”.





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VISION INSURANCE

SUMMARY OF BENEFITS
Level of Coverage from an
Non-Anthem Doctor or Provider Level
Description
Anthem doctor
of Reimbursement
Blue View Vision - Exam Only
Frequency: Once every 12 months
$15 copay, then covered in full
Reimbursed up to $50
(included with your medical plan
election)



Blue View Vision - Materials Only


(Voluntary)
Eyeglass Frames
$130 allowance, then 20% off any remaining
Reimbursed up to $70
Frequency: Once every 12 months
balance
Standard Plastic Lenses
Frequency: Once every 12 months
One time materials copay of $15

(from last date of service)
Standard plastic single vision lenses
$15 copay, then covered in full
Reimbursed up to $50
Standard plastic lined bifocal lenses
$15 copay, then covered in full
Reimbursed up to $75
Standard plastic lined trifocal lenses
$15 copay, then covered in full
Reimbursed up to $100
Lenses include factory scratch coating at no additional cost. Polycarbonate and photochromic lenses are covered for dependent children under age
19 with no additional cost.
Contact Lenses*
Frequency: Once every 12 months (from


last date of service)
$130 allowance, then 15% off any remaining
Elective conventional lenses
Reimbursed up to $110
balance
Elective disposable lenses
$130 allowance
Reimbursed up to $110
Non-elective contact lenses
Covered in full
Reimbursed up to $210 allowance
Contact lens exam (Fitting &
Copayment up to $55
N/A
Evaluation)
* Contact lenses are in lieu of lenses and/or frame.
In-Network Member Cost
Eyeglass lens upgrades

(after any applicable copay)
When obtaining eyewear from a Blue
 Transitions lenses (Adults)
$75
View Vision Provider, you may choose
 Standard Polycarbonate (Adults)
$40
to upgrade your new eyeglass lenses at
 UV Coating
$15
a discounted cost. Eyeglass lens
 Progressive Lenses ¹

copayment applies.
o Standard
$65
o Premium Tier 1
$85
o Premium Tier 2
$95
o Premium Tier 3
$110
 Anti-Reflective Coating ²

o Standard
$45
o Premium Tier 1
$57
o Premium Tier 2
$68
 Other Add-ons and Services
20% off retail price
¹ Please ask your provider for his/her recommendation as well as the progressive brands by tier.
² Please ask your provider for his/her recommendation as well as the coating brands by tier.
Laser vision correction surgery


LASIK Refractive Surgery
Discount per eye
For more information please visit
www.anthem.com/specialoffers and
select vision care.
If you see an out-of-network provider, you must pay the cost in full and submit an out-of-network claim form for reimbursement up to the allowed amount.



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VISION INSURANCE

Eyeglasses
 Lenses - Anthem Blue View Vision covers single vision, lined bifocal and lined trifocal lenses in full less the applicable copay.
 Covered Lens enhancements - Covered lens enhancements for all members include factory-scratch resistant coating.
Participants receive discounts on non-covered lens enhancements such as anti-reflective coating, tinting, UV protection and
progressive lenses.
 Frames – Frames are covered up to $130 allowance. Participants receive a 20% discount on any amount over the frame
allowance.

Contact Lenses
 Contacts are available in lieu of frames and/or lenses. If you elect to purchase contacts, the plan pays $130 towards the
purchase of the contacts. The contact benefit allowance must be used at one time. You cannot carry over any unused
balance within the year. The contact lens exam (fitting and evaluation) copay is up to $55.

Laser VisionCare Program
 Potential candidates for laser vision correction surgery can learn about this procedure by visiting
www.anthem.com/specialoffers. Anthem BVV partners with Tru Vision & Premier Lasik to offer multiple discount options for
Lasik surgery.

NOTE: These procedures are eligible expenses within the Flexible Benefit Plan Health Care Spending Account.

Additional Eyewear Benefits
 Additional sets of glasses can be obtained on the same date as an exam by the same provider at a 40% discount.

Low Vision Benefit
 The Low Vision Benefit is available to covered persons who have severe visual problems that are not correctable with regular
lenses and is subject to prior approval from Anthem’s Optometric Consultants.


Anthem Network
Non-Anthem
Provider Benefit
Provider Benefit
Supplementary Testing
Covered in Full
Up to $125.00
Complete low vision analysis and diagnosis that includes a comprehensive examination of visual functions,
including the prescription of corrective eyewear or vision aids where indicated.
Supplementary Care Aids
25% copay
Up to 75% of Cost
Subsequent low vision therapy as Visually Necessary or appropriate.
Copayment


75% of the authorized benefits payable by the Company and 25% payable by Covered Person.

The maximum low vision benefit available is $1,000 (excluding copayments) every two years.

Non-Anthem Providers
If patients choose a Non-Anthem provider, they should pay the entire bill and submit a copy of the itemized
receipt to Anthem along with a claim form that can be downloaded from www.anthem.com. If the patient
prefers, they can contact Customer Service at 1-866-723-0515 to have a form sent directly to them. Claims
must be submitted to Anthem within 180 days of the date of service. The address for submitting the claims
is located directly on the form.

Anthem Plan Limitations
This plan is designed to cover your visual needs rather than cosmetic eyewear. You will be responsible for
any additional charge on services or eyewear other than those covered by Anthem.



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VISION INSURANCE

There is no benefit for professional services or eyewear for the following:
Orthoptics or vision training and non-prescription lenses or glasses.
Lenses and frames furnished under the plan which are lost, stolen or broken during a current 12-month
benefit period.
Medical or surgical treatment of the eyes.
Services or eyewear provided as the result of a Worker’s Compensation Law or similar legislation, or
obtained through or required by any government agency or program whether Federal, state or any
subdivision thereof.
Any service or eyewear provided by any other vision care plan or group benefit plan containing benefits
for vision care.

Exceptions to these limitations may be considered on an individual basis upon the request of the eye care
professional. Exceptions must be granted through prior authorization of Anthem and will only be
considered when the exception is deemed necessary to the patient’s visual welfare.

NOTE: This is only an overview of your vision plan choices. Review the specific vision brochures pertaining to each plan for further details
and explanations. If discrepancies are found, depend upon the certificate of coverage itself for accuracy.









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