Vision Summary

SM Blue View Vision FS.B.0.0.150.150 Welcome to your Blue View Vision plan! You have many choices when it comes to using your benefits. As a Blue View Vision plan member, you have access to one of the nation’s largest vision networks. You may choose from many private practice doctors, local optical stores, and national retail stores including LensCrafters®, Target Optical®, and most Pearle Vision® locations. You may also use your in-network benefits to order eyewear online at Glasses.com and ContactsDirect.com. To locate a participating network eye care doctor or location, log in at anthem.com/ca, or the Sydney app. You may also call member services for assistance at 1-866-723-0515. Out-of-Network – If you choose to, you may instead receive covered benefits outside of the Blue View Vision. Just pay in full at the time of service, obtain an itemized receipt, and file a claim for reimbursement up to your maximum out-of-network allowance. Your vision plan includes coverage for routine eye exams and prescription eyewear from your choice of eye care providers. YOUR BLUE VIEW VISION PLAN BENEFITS IN-NETWORK OUT-OF-NETWORK FREQUENCY Routine Eye Exam A comprehensive eye examination $0 Copay Reimbursed Up To $42 Once every calendar year Eyeglass Frames One pair of eyeglass frames $150 Allowance, then 20% Reimbursed Up To $45 Once every other calendar off any remaining balance year Eyeglass Lenses (instead of contact lenses) One pair of standard plastic prescription lenses  Single vision lenses $0 Copay Reimbursed Up To $40 Once every calendar year  Bifocal lenses $0 Copay Reimbursed Up To $60  Trifocal lenses $0 Copay Reimbursed Up To $80 Eyeglass Lens Enhancements When obtaining covered eyewear from a Blue View Vision provider, you may choose to add any of the following lens enhancements at no extra cost  Lenses (for a child under age 19) $0 Copay No allowance when Same as covered eyeglass  Standard polycarbonate (for a child under age 19) $0 Copay obtained out-of-network lenses  Factory Scratch Coating $0 Copay Contact Lenses (instead of eyeglass lenses) Contact lens allowance will only be applied toward the first purchase of contacts made during a benefit period. Any unused amount remaining cannot be used for subsequent purchases in the same benefit period, nor can any unused amount be carried over to the following benefit period.  Elective conventional (non-disposable) $150 Allowance, then 15% Reimbursed Up To $105 OR off any remaining balance  Elective disposable $150 Allowance Reimbursed Up To $105 Once every calendar year OR (no additional discount)  Non-elective (medically necessary) Covered in full Reimbursed Up To $210 This is a primary vision care benefit intended to cover only routine eye examinations and corrective eyewear. Blue View Vision is for routine eye care only. If you need medical treatment for your eyes, visit a participating eye care doctor from your medical network. Benefits are payable only for expenses incurred while the group and insured person’s coverage is in force. This information is intended to be a brief outline of coverage. All terms and conditions of coverage, including benefits and exclusions, are contained in the member’s policy, which shall control in the event of a conflict with this overview. This benefit overview is only one piece of your entire enrollment package. . EXCLUSIONS & LIMITATIONS (not a comprehensive list – please refer to the member Certificate of Coverage for a complete list) Combined Offers. Not to be combined with any offer, coupon, or in-store Lost or Broken Lenses or Frames. Any lost or broken lenses or frames are not eligible advertisement. for replacement unless the insured person has reached his or her normal service interval Excess Amounts. Amounts in excess of covered vision expense. as indicated in the plan design. Sunglasses. Plano sunglasses and accompanying frames. Non-Prescription Lenses. Any non-prescription lenses, eyeglasses or contacts. Plano Safety Glasses. Safety glasses and accompanying frames. lenses or lenses that have no refractive power. Not Specifically Listed. Services not specifically listed in this plan as covered services. Orthoptics. Orthoptics or vision training and any associated supplemental testing Contract code: 4NYJ

OPTIONAL SAVINGS AVAILABLE FROM BLUE VIEW VISION IN-NETWORK PROVIDERS ONLY In-Network Member Cost (Discounts are not covered benefits under your vision plan and will not be listed in your certificate of coverage.) (after any applicable copay) Retinal Imaging - at member’s option, can be performed at time of eye exam Not More Than $39 Eyeglass lens upgrades  lenses (Adults) $75 When obtaining eyewear from a Blue View Vision  Standard Polycarbonate (Adults) $40 provider, you may choose to upgrade your new eyeglass  Tint (Solid and Gradient) $15 lenses at a discounted cost. Eyeglass lens copayment  UV Coating $15 applies.  Progressive Lenses1  Standard $55  Premium Tier 1 $85  Premium Tier 2 $95  Premium Tier 3 $110  Premium Tier 4 $175 2  Anti-Reflective Coating  Standard $45  Premium Tier 1 $57  Premium Tier 2 $68  Premium Tier 3 $85  Other Add-ons (i.e. high index lenses, anti-fog 20% off retail price coating) Additional Pairs of Eyeglasses  Complete Pair 40% off retail price Anytime from any Blue View Vision network provider  Eyeglass materials purchased separately 20% off retail price Eyewear Accessories  Items such as non-prescription sunglasses, lens cleaning supplies, contact lens solutions, 20% off retail eyeglass cases, etc. Conventional Contact Lenses  Discount applies to materials only 15% off retail price (non-disposable type)  Contact lens fit and follow-up  Standard contact lens fitting3 Up to $55 A contact lens fitting and up to two follow-up visits  Premium contact lens fitting4 10% off retail price are available to you once a comprehensive eye exam has been completed. 1 Please ask your provider for his/her recommendation as well as the available progressive brands by tier. 2 Please ask your provider for his/her recommendation as well as the available anti-reflective brands by tier. 3 Standard fitting includes spherical clear lenses for conventional wear and planned replacement. Examples include but are not limited to disposable and frequent replacement. 4 Premium fitting includes all lens designs, materials and specialty fittings other than standard contact lenses. Examples include but are not limited to toric and multifocal. Cannot be combined with any other offer. Discounts are subject to change without notice. Discounts are not covered benefits under your vision plan and will not be listed in your certificate of coverage. Discounts will be offered from in-network providers except where State law prevents discounting of products and services that are not covered benefits under this plan. Discounts on frames will not apply if the manufacturer has imposed a no discount on sales at retail and independent provider locations. Some of our in-network providers include: ADDITIONAL SAVINGS Savings on items like additional eyewear after your benefits have been used, non-prescription sunglasses, hearing aids and even LASIK laser vision correction surgery are available through a variety of vendors. Just log in at anthem.com/ca, select discounts, then Vision, Hearing & Dental. * Discounts cannot be used in conjunction with your covered benefits. OUT-OF-NETWORK If you choose to receive covered services or purchase covered eyewear from an out-of-network provider, network discounts will not apply and you will be responsible for payment of services and/or eyewear materials at the time of service. Please complete an out-of-network claim form and submit it along with your itemized receipt to the fax number, email address, or mailing address below. To download a claim form, log in at anthem.com/ca, or from the home page menu under Support select Forms, click Change State to choose your state, and then scroll down to Claims and select the Blue View Vision Out-of-Network Claim Form. You may instead call member services at 1-866-723-0515 to request a claim form. TO FAX: 866-293-7373 TO EMAIL: [email protected] TO MAIL: Blue View Vision Attn: OON Claims P.O. Box 8504 Mason, OH 45040-7111 Transitions are registered trademarks of Transitions Optical, Inc. Anthem Blue Cross Life and Health Insurance Company is an independent licensee of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association.

Get Help in Your Language Curious to know what all this says? We would be too. Here’s the English version: You have the right to get this information and help in your language for free. Call the Member Services number on your ID card for help. (TTY/TDD: 711) Separate from our language assistance program, we make documents available in alternate formats for members with visual impairments. If you need a copy of this document in an alternate format, please call the customer service telephone number on the back of your ID card. Spanish Tiene el derecho de obtener esta información y ayuda en su idioma en forma gratuita. Llame al número de Servicios para Miembros que figura en su tarjeta de identificación para obtener ayuda. (TTY/TDD: 711) Arabic *+,-./01 23 45-617 89:;3 ?0, @ABA/17 C-D,E7 F-G+H I=:3 JKL7 .-MN-OG 2

Russian xy z{||}| ~€‚ ~‚ƒ„…z}† ‡€ˆˆ„‰ zˆŠ‚{€‹z‰ z ~‚{‚Œ† ˆ€ €|{ Žy| ‘|’~ƒ€}ˆ‚ “ƒŽ ~‚ƒ„…|ˆzŽ ~‚{‚Œz ‚ˆz}|  ‚}‡|ƒ ‚‘’ƒ„”z€ˆzŽ „…€’}ˆz‚ ~‚ ˆ‚{|„• „€€ˆˆ‚{„ ˆ€ €|– z‡|ˆ}zŠz€‹z‚ˆˆ‚– €}| (TTY/TDD: 711) Tagalog May karapatan kayong makuha ang impormasyon at tulong na ito sa ginagamit ninyong wika nang walang bayad. Tumawag sa numero ng Member Services na nasa inyong ID card para sa tulong. (TTY/TDD: 711) Thai ท่านมีสิทธิขอรับบริการสอบถามข้อมูลและความช่วยเหลือในภาษาของท่านฟรี โทรไปที่หมายเลขฝ่ายบริการสมาชิกบนบัตรประจำตัวของท่านเพื่อขอความช่วยเหลือ(TTY/TDD: 711) Vietnamese Quý ™ có (š ›  œ phí thông tin này và  ¡ giúp ¢ ngôn  £ ¤ quý ™ Hãy ¦ cho § ™ ¨© Thành Viên trên « ID ¤ quý ™ ¬­ ¬®¡ giúp ¬¯ (TTY/TDD: 711) It’s important we treat you fairly That’s why we follow federal civil rights laws in our health programs and activities. We don’t discriminate, exclude people, or treat them differently on the basis of race, color, national origin, sex, age or disability. For people with disabilities, we offer free aids and services. For people whose primary language isn’t English, we offer free language assistance services through interpreters and other written languages. Interested in these services? Call the Member Services number on your ID card for help (TTY/TDD: 711). If you think we failed to offer these services or discriminated based on race, color, national origin, age, disability, or sex, you can file a complaint, also known as a grievance. You can file a complaint with our Compliance Coordinator in writing to Compliance Coordinator, P.O. Box 27401, Mail Drop VA2002-N160, Richmond, VA 23279. Or you can file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights at 200 Independence Avenue, SW; Room 509F, HHH Building; Washington, D.C. 20201 or by calling 1-800-368-1019 (TDD: 1- 800-537-7697) or online at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf. Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.