Marketing directo

The vision benefit is a “carve-out” benefit meaning that it is included in the member’s enrollment in the medical plan, but the covered vision services have their own schedule of benefits and network providers separate from medical benefits. That is, the medical plan deductibles and co-insurance do not apply to vision benefits, and the amount the member pays for vision services do not accumulate toward the medical plan deductible or out-of- pocket maximums. Network vision providers can be found using the FIND A DOCTOR tool at www.anthem.com. Select Vision as the first step and then Blue View Vision as the insurance plan to use.

The vision benefit is for routine eye care and corrective eye care only. For medical treatment of the eyes, visit a medical network eye care physician. Medical eye care includes services for such conditions as eye injuries, glaucoma, and retinal detachment. The medical deductible, co-insurance and out-of-pocket maximums apply to medical eye services.

All Covered Services are subject to the exclusions listed in the Vision exclusion section and all other conditions and limitations of the plan booklet. The amount payable for Covered Services varies depending on whether services are receive from a Network Provider or a Non-Network Provider and whether or not optional services and/or custom materials are selected rather than standard services and supplies. Payment amounts are specified in the Benefit Summary.

The following are Covered Services:

• Routine vision examination once a year per member • Standard eyeglass frames and lenses

• Non-elective contact lenses

• Elective contact lenses chosen instead of eyeglasses

Optional savings are available from In-network providers for additional eyeglasses and certain elective upgrades such as multifocal, photochromatic, tinted, and coated lenses.

Services and materials obtained through a Non-Network Provider are subject to the same exclusions and limitations as services through a Network Provider.

VisiOn EyE ExaMinatiOn

The Plan covers a comprehensive eye examination including dilation as needed minus any applicable co-payment. The eye examination may include the following:

• Case history

• Recording corrected and uncorrected visual acuity • Examination of the internal and external eye • Pupillary reflexes

• Binocular vision

• Objective refraction and subjective refraction • Glaucoma test

• Slit lamp exam (biomicroscopy) • Dilation

Blue View Vision — Continued • Color vision

• Depth perception

• Diagnosis and treatment plan

DEFinitiOns

Elective Contact Lenses - All prescription contact Lenses that are cosmetic in nature or Non-Elective Contact Lenses.

Lenses - Materials prescribed for the visual welfare of the patient. Materials would include single vision, bifocal, trifocal or other more complex lenses.

Non-Elective Contact Lenses – Contact Lenses which are provided for reasons that are not cosmetic in nature. Non- Elective Contact Lenses are Covered Services when the following conditions have been identified or diagnosed:

• Extreme visual acuity or other functional problems that cannot be corrected by spectacle Lenses; or • Keratoconus-unusual cone-shaped thinning of the cornea of the eye which usually occurs before the age

of 20 years; or

• High Ametropia-unusually high levels of near sightedness, far sightedness, or astigmatism are identified; or • Anisometropia - when one eye requires a much different prescription than the other eye.

MEMBER REsPOnsiBility

MEDical sERVicE/PROcEDuRE network non-network

routine eye exam (once every plan year) _{then covered in full}$10 copay, $42 allowance

eyeglass frames

Once every plan year you may select an eyeglass frame and receive an allowance toward the purchase price.

$110 allowance, then 20% off any

remaining balance $55 allowance eyeglass lenses (standard)

Once every plan year you may receive any one of the following lens options:

Standard plastic single vision lenses (1 pair)

$20 copy, then covered in full

$40 allowance

Standard plastic bifocal lenses (1pair) $60 allowance

Standard plastic trifocal lenses (1 pair) $80 allowance

Standard plastic lenticular lenses (1 pair) $55 allowance

eyeglass lens enhancements

When obtaining covered eyewear from a Blue View Vision provider, you may add any of the following lens enhancements at no extra cost.

Transitions Lenses (for a child under age 19) Standard Polycarbonate (for a child under age 19) Factory Scratch Coating

$0 after eyeglass lens copay

No allowance on lens enhancements when obtained out-of-network

MEMBER REsPOnsiBility

MEDical sERVicE/PROcEDuRE network non-network

contact lenses (once every plan year)

You may choose contact lenses instead of eyeglass lenses and receive an allowance toward the cost of a supply of contact lenses.

Elective Conventional Lenses then 15% off any $110 allowance,

remaining balance $105 allowance Elective Disposable Lenses _{(no additional discount)}$110 allowance $105 allowance Non-Elective Contact Lenses Covered in full $210 allowance

Your contact lens allowance can only be applied toward the first purchase of contacts you make during a benefit period. Any unused amount remaining cannot be used for subsequent purchases made during the same benefit period, nor can any unused amount be carried over to the following benefit period.

MEMBER REsPOnsiBility

MEDical sERVicE/PROcEDuRE network non-network

retinal imaging

(at member’s option can be performed at time of eye exam) Not more than $39

Not Covered

eyeglass lens upgrades

When obtaining eyewear from a Blue View Vision provider, you may choose to upgrade your new eyeglass lenses at a discounted cost. Eyeglass lens copayment applies.

Transitions lenses (Adults) $75

Standard Polycarbonate (Adults) $40

Tint (Solid and Gradient) $15

UV Coating $15 Progressive Lenses1 Standard $65 Premium Tier 1 $85 Premium Tier 2 $95 Premium Tier 3 $110 Anti-Reflective Coating2 Standard $45 Premium Tier 1 $57 Premium Tier 2 $68

Blue View Vision — Continued

MEMBER REsPOnsiBility

MEDical sERVicE/PROcEDuRE network non-network

additional pairs of eyeglasses (complete pair) 40% off retail price

Not Covered Anytime from any Blue View Vision

(eyeglass materials purchased separately) 20% off retail price eyewear accessories

Items such as non-prescription sunglasses, lens cleaning

supplies, contact lens solutions, eyeglass cases, etc. 20% off retail price

contact lens fit and follow-up

A contact lens fitting and up to two follow-up visits are available to you once a comprehensive eye exam has been completed.

Standard contact lens fitting3 _{Up to $55}

Premium contact lens fitting4 _{10% off retail price}

conventional contact lenses

(Discount applies to materials only) 15% off retail price

laser vision correction sugery

LASIK refractive surgery

(For more information, go to anthem.com/specialoffers and select vision care.)

Discount per eye 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.}

3_{A standard contact lens fitting includes spherical clear contact lenses for conventional wear and planned replacement. Examples}

include but are not limited to disposable and frequent replacement.

4_{A premium contact lens fitting includes all lens designs, materials and specialty fittings other than standard contact lenses. Examples}

include but are not limited to toric and multifocal.