Anthem Vision Summary Plan Description
BCBS
This is a summary of your vision benefits (review certificate for plan details)
| Anthem Vision Benefits | In-Network Provider | Non-Network Provider |
| Vision Examination: Each member is
entitled to a comprehensive vision examination by an Anthem Provider. 500-30-80/50 500-35-50/50 1000-35-80/50 2000-40-70/50 3000-70/50 Availability; once every 12 month*
|
$30 Copayment $35 Copayment $35 Copayment $40 Copayment $40 Copayment
|
Up to $35 Up to $35 Up to $35 Up to $35 5Up to $35
|
| Lenses: A choice of glass or plastic
(CR39) lenses in single vision, and bifocal or trifocal (FT25-28); lenses up
to 55mm; and all ranges of prescriptions. 500-30-80/50 500-35-50/50 1000-35-80/50 2000-40-70/50 3000-70/50 |
$30 Copay applies to lenses & frames $35 Copay applies to lenses & frames $35 Copay applies to lenses & frames $40 Copay applies to lenses & frames $40 Copay applies to lenses & frames
|
|
| Single Vision Lenses 500-30-80/50 500-35-50/50 1000-35-80/50 2000-40-70/50 3000-7050
|
$30 Copayment $35 Copayment $35 Copayment $40 Copayment $40 Copayment
|
Up to $25 Up to$25 Up to $25 Up to $25 Up to $25
|
| Bifocal
Lenses (pair) 500-30-80/50 500-35-50/50 1000-35-80/50 2000-40-70/50 3000-7050
|
$30 Copayment $35 Copayment $35 Copayment $40 Copayment $40 Copayment
|
Up to $25 Up to$25 Up to $25 Up to $25 Up to $25
|
| Progressive Lenses (pair) 500-30-80/50 500-35-50/50 1000-35-80/50 2000-40-70/50 3000-7050
|
$30 Copayment $35 Copayment $35 Copayment $40 Copayment $40 Copayment Member pays difference, of maximum allowable amount equal to bifocal amount. |
Up to $40 Up to $40 Up to $40 Up to $40 Up to $40
|
| Trifocal
Lenses (pair) 500-30-80/50 500-35-50/50 1000-35-80/50 2000-40-70/50 3000-7050
|
$30 Copayment $35 Copayment $35 Copayment $40 Copayment $40 Copayment
|
Up to $55 Up to $55 Up to $55 Up to $55 Up to $55
|
| Lenticular 500-30-80/50 500-35-50/50 1000-35-80/50 2000-40-70/50 3000-7050
|
$30 Copayment $35 Copayment $35 Copayment $40 Copayment $40 Copayment
|
Up to $80 Up to $80 Up to $80 Up to $80 Up to $80
|
| Frames: Maximum allowable amount of
$120 (retail) for frames purchased from network provider. Member pays
preferred price in excess of maximum allowable amount. 500-30-80/50 500-35-50/50 1000-35-80/50 2000-40-70/50 3000-7050 Availability; Once every 24 months* |
$30 Copayment $35 Copayment $35 Copayment $40 Copayment $40 Copayment
|
Up to $45 Up to $45 Up to $45 Up to $45 Up to $45
|
| Contact Lenses*** Elective-Members
have a $105 plan allowance per benefit period toward cosmetic contact
lenses in lieu of the frame and lens benefits. 500-30-80/50 500-35-50/50 1000-35-80/50 2000-40-70/50 3000-7050
|
If the member chooses contact lenses greater
than the plan allowance, the member is responsible for the difference 30 Copayment $35 Copayment $35 Copayment $40 Copayment $40 Copayment
|
Up to $80 Up to $80 Up to $80 Up to $80 Up to $80
|
| Medically Necessary
500-30-80/50 500-35-50/50 1000-35-80/50 2000-40-70/50 3000-7050 Availability: once every 12 months* |
plan provides 10% discount on disposable
lenses and 15% on other traditional lenses $30 Copayment $35 Copayment $35 Copayment $40 Copayment $40 Copayment
|
Up to $210 Up to $210 Up to $210 Up to $210 Up to $210
|
Important:
This plan overview is intended to be a brief outline of
coverage. All terms and conditions of coverage, including
benefits and exclusions, are contained in the Certificate,
which shall control in the event of a conflict with this
overview.
These programs may be terminated or modified at the discretion
of Anthem Blue Cross and Blue Shield.
The brief description of the plans provided through Anthem Blue Cross and Blue Shield are a general guide for more detailed description please contact Denise Brown about coverage, benefits, limitations, exclusions and any additional information about cost and enrollment.
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Forging a New Path to Better Health Care
Denise Brown Owner/Broker
Direct Health & Life of Nevada
Authorized Nevada Premier Agent
Phone: (702) 349-7579
email: dee2000@cox.net
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