Page 11 - Quarles

Vision Benefits

If you enroll in one of the medical plans,
you automatically receive the Basic Plan
for vision care. You have the option to buy
up coverage to the Preferred Plan and the
cost will be added to your medical plan
contribution rate.

Basic Plan: If you enroll in a medical
plan, the Basic Vision Plan is included and
offers you discounts on both services and
materials.

Preferred Plan: You have the option to
buy-up to the Preferred Plan. It covers a
greater percentage of the cost for lenses, frames and contacts, as shown in the
following table.

Networks: Benefits are available through any vision care professional you choose. However, using
Anthem Blue View Vision network providers will save you money. When using an out-of- network provider,
you are required to pay the provider in full at the time of services and file a claim for reimbursement. The
amount you receive will likely be less than what your network provider charges.

Vision Benefits

Basic Plan Preferred Plan
(included with (Optional Buy-up Plan)
Medical Plans)
Plan Features In-Network Out-of-Network
In-Network and
Eye exam Out-of-Network Plan pays 100% Plan pays a
(once every calendar year) In-Network: Plan pays after $15 copay $30 allowance
100% after $15 copay
Frames Out-of-Network: Plan Plan pays $130 allowance, Plan pays a
(once every two calendar pays a $30 allowance then 20% off the $45 allowance
years) remaining balance
Lenses 35%
(once every calendar year) off retail price Plan pays 100% Plan pays:
after $25 copay $25 allowance
Single vision $50 copay $40 allowance
Bifocal $70 copay Elective Conventional $55 allowance
Trifocal $105 copay Lenses: Plan pays $130
allowance, then 15% off Elective Conventional
Contacts 15% any remaining balance Lenses: Plan pays $105
(once every calendar year off retail for conventional Elective Disposable allowance
in lieu of frames and lenses) Lenses: Plan pays a $130 Elective Disposable
Note: You can also order (non-disposable) allowance (no additional Lenses: Plan pays $105
contacts through 1-800 discount) allowance
CONTACTS Non-Elective Contact Non-Elective Contact
Lenses: Plan pays 100% Lenses: Plan pays $210
allowance

10 2016-2017 Benefits Guide