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.