Blue View Plan - Health Home 1

SUMMARY OF FEATURESBlue View PlanThis is an overview of coverage. Please refer to theExclusions and Limitations in the Blue View Visionbrochure for additional plan provisions. Pleasereview the Exclusions and Limitations prior toapplying for coverage. A comprehensive descriptionof coverage, benefits, and limitations is contained inthe Certificate.

BLUE VIEW PLANEye ExaminationLensesContact Lenses*FramesIn-Network CopaymentEYE EXAMINATION COPAYIn-Network BenefitsEYE EXAMINATIONLENSES (Standard)Single visionBifocal lensesProgressive lensesTrifocal lensesFRAMECONTACT LENSESElectiveConventionalDisposableNon-elective**ADDITIONAL DISCOUNTSOut-of-Network ReimbursementEYE EXAMINATIONLENSES (Standard)Single visionBifocal lensesProgressive lensesTrifocal lensesFRAMECONTACT LENSESElectiveConventionalDisposableNon-elective**Blue ViewEvery 12 monthsEvery 24 monthsEvery 24 monthsEvery 24 months$25Covered up to a comprehensive level exam with dilation as necessary after exam copayPlastic lenses in single vision, bifocal, or trifocalCovered in full after exam copayCovered in full after exam copayCovered in full after exam copay + $65Covered in full after exam copayCovered up to $120 retail value after exam copay. Members receive a 20% discount on theamount over the allowanceBenefit allowance applies to fit, follow-up & materialsCovered up to $115 allowance after exam copay. 15% off balance over allowanceCovered up to $115 allowance after exam copayCovered in full after exam copayDiscounts available from Participating ProvidersReimbursed up to $49Reimbursed up to $35Reimbursed up to $49Reimbursed up to $49Reimbursed up to $74Reimbursed up to $50Reimbursed up to $92Reimbursed up to $92Reimbursed up to $250*Coverage for this PPO vision plan includes choice of frames and lenses OR contacts, not both.** Non-elective contacts are those prescribed following cataract surgery or for extreme visual acuity or other functional problems not treatable by spectacle lens.Using Your Blue View PlanAnthem Blue Cross Life and Health Insurance Company understands that vision benefits are essential to maintaining your overallhealth and wellness, and we are committed to your vision care. Through your Blue View plan, not only do you have access to 4,500providers and provider locations (including a market-leading number of independent ophthalmologists and optometrists), but youalso get the convenience of LensCrafters SM , Target Optical, Sears Optical, and most Pearle Vision stores. Many of the providers areopen in the evenings and on weekends, so you have the flexibility to schedule an appointment that allows you less time away fromwork.Members can save with their covered benefit and long after their benefits have been exhausted. Members will enjoy a 20%discount off any remaining balance for frames purchased over the frame allowance. And they can save 15% to 40% onnon-covered materials such as additional pairs of glasses, conventional contact lenses, lens treatments, some non-prescriptionsunglasses and other accessory items. Members can access this savings from any participating provider as often as they choose.You simply choose a Blue View Vision network eye care provider, make an appointment, present your membership card, pay youreye examination copayment and any remaining balance. The provider will verify your eligibility and take care of all the necessarypaperwork. To select an eye care provider or location, you can access the Provider Directory on www.anthem.com/ca or callCustomer Service at (866) 723-0515.Anthem Blue Cross Life and Health Insurance Company is an independent licensee of the Blue Cross Association. ® ANTHEM is a registered trademark. ® The Blue Cross name andsymbol are registered marks of the Blue Cross Association.ECASB2248BEN 4/08