Full Text
Contract code: 4M6T Blue View VisionSM FS.B.10.20.130.130 (4M6T) Pickens County BOC January 1, 2023 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, or from the home page menu under Care, select Find a Doctor. You may also call member services for assistance at 1-[PHONE REDACTED]. Out-of-Network – If you choose to, you may instead receive covered benefits outside of the Blue View Vision network. 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 BLUE VIEW VISION PLAN BENEFITS IN-NETWORK OUT-OF-NETWORK FREQUENCY Routine Eye Exam A comprehensive eye examination $10 Copay Reimbursed Up To $42 Once every calendar year Eyeglass Frames One pair of eyeglass frames $130 Allowance, then 20% off any remaining balance Reimbursed Up To $45 Once every other calendar year Eyeglass Lenses (instead of contact lenses) One pair of standard plastic prescription lenses Single vision lenses Bifocal lenses Trifocal lenses $20 Copay $20 Copay $20 Copay Reimbursed Up To $40 Reimbursed Up To $60 Reimbursed Up To $80 Once every calendar year 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) Standard polycarbonate (for a child under age 19) Factory Scratch Coating $0 Copay $0 Copay $0 Copay No allowance when obtained out-of-network Same as covered eyeglass lenses 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) OR Elective disposable OR Non-elective (medically necessary) $130 Allowance, then 15% off any remaining balance $130 Allowance (no additional discount) Covered in full Reimbursed Up To $105 Reimbursed Up To $105 Reimbursed Up To $210 Once every calendar year 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 advertisement. Excess Amounts. Amounts in excess of covered vision expense. Sunglasses. Plano sunglasses and accompanying frames. Safety Glasses. Safety glasses and accompanying frames. Not Specifically Listed. Services not specifically listed in this plan as covered services. Lost or Broken Lenses or Frames. Any lost or broken lenses or frames are not eligible for replacement unless the insured person has reached his or her normal service interval as indicated in the plan design. Non-Prescription Lenses. Any non-prescription lenses, eyeglasses or contacts. Plano lenses or lenses that have no refractive power. Orthoptics. Orthoptics or vision training and any associated supplemental testing ---PAGE BREAK--- Transitions are registered trademarks of Transitions Optical, Inc. Anthem Blue Cross and Blue Shield is the trade name of Blue Cross and Blue Shield of Georgia, Inc. Independent licensee of the Blue Cross and Blue Shield Association. OPTIONAL SAVINGS AVAILABLE FROM BLUE VIEW VISION IN-NETWORK PROVIDERS ONLY In-Network Member Cost (after any applicable copay) Retinal Imaging – at member’s option, can be performed a time of eye exam Not more than $39 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. lenses (Adults) Standard Polycarbonate (Adults) Tint (Solid and Gradient) UV Coating Progressive Lenses1 Standard Premium Tier 1 Premium Tier 2 Premium Tier 3 Premium Tier 4 Anti-Reflective Coating2 Standard Premium Tier 1 Premium Tier 2 Premium Tier 3 Other Add-ons $75 $40 $15 $15 $55 $85 $95 $110 $175 $45 $57 $68 $85 20% off retail price Additional Pairs of Eyeglasses Anytime from any Blue View Vision network provider Complete Pair Eyeglass materials purchased separately 40% off retail price 20% off retail price Eyewear Accessories Items such as non-prescription sunglasses, lens cleaning supplies, contact lens solutions, eyeglass cases, etc. 20% off retail 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 Premium contact lens fitting4 Up to $55 10% off retail price Conventional Contact Lenses Discount applies to materials only 15% off retail price 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 AVAILABLE THROUGH ANTHEM’S SPECIAL OFFERS PROGRAM 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, 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, 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-[PHONE REDACTED] .to request a claim form. TO FAX: [PHONE REDACTED] TO EMAIL: [EMAIL REDACTED] TO MAIL: Blue View Vision Attn: OON Claims P.O. Box 8504 Mason, OH 45040-7111 ---PAGE BREAK--- 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) Amharic ይህንን መረጃ እና እገዛ በቋንቋዎ በነጻ እገዛ የማግኘት መብት አልዎት። ለእገዛ በመታወቂያዎ ላይ ያለውን የአባል አገልግሎቶች ቁጥር ይደውሉ። (TTY/TDD: 711) Arabic يحق لك الحصول على هذه المعلومات والمساعدة بلغتك مجانًا. اتصل برقم خدمات األعضاء الموجود على بطاقة التعريف الخاصة بك( للمساعدةTTY/TDD:711 ) Chinese 您有權使用您的語言免費獲得該資訊和協助。請撥打您的 ID 卡上的成員服務號碼尋求協助。(TTY/TDD: 711) Farsi شما اين حق را داريد که اين اطالعات و کمکها را به صورت رايگان به زبان خودتان دريافت کنيد. برای دريافت کمک به شماره مرکز خدمات اعضاء که بر روی کارت شناسايی.تان درج شده است، تماس بگيريد (TTY/TDD: 711) French Vous avez le droit d’accéder gratuitement à ces informations et à une aide dans votre langue. Pour cela, veuillez appeler le numéro des Services destinés aux membres qui figure sur votre carte d’identification. (TTY/TDD: 711) German Sie haben das Recht, diese Informationen und Unterstützung kostenlos in Ihrer Sprache zu erhalten. Rufen Sie die auf Ihrer ID-Karte angegebene Servicenummer für Mitglieder an, um Hilfe anzufordern. (TTY/TDD: 711) Gujarati તમે તમારી મફતમાાં આ માહિતી અને મદદ મેળવવાનો અહિકાર િરાવો મદદ માટે તમારા આઈડી કાડડ પરના મેમ્બર સહવડસ નાંબર પર કોલ કરો. (TTY/TDD: 711) Haitian Ou gen dwa pou resevwa enfòmasyon sa a ak asistans nan lang ou pou gratis. Rele nimewo Manm Sèvis la ki sou kat idantifikasyon ou a pou jwenn èd. (TTY/TDD: 711) Hindi आपके पास यह जानकारी और मदद अपनी भाषा मुफ़्त प्राप्त करने का अधिकार मदद के धिए अपने ID कार्ड पर सदस्य सेवाएँ नंबर पर करें। (TTY/TDD: 711) Japanese この情報と支援を希望する言語で無料で受けることができます。支援を受けるには、IDカードに記載されているメンバーサービス番号に電話 してください。(TTY/TDD: 711) ---PAGE BREAK--- Korean 귀하에게는 무료로 이 정보를 얻고 귀하의 언어로 도움을 받을 권리가 있습니다. 도움을 얻으려면 귀하의 ID 카드에 있는 회원 서비스 번호로 전화하십시오. (TTY/TDD: 711) Portuguese-Europe Tem o direito de receber gratuitamente estas informações e ajuda no seu idioma. Ligue para o número dos Serviços para Membros indicado no seu cartão de identificação para obter ajuda. (TTY/TDD: 711) Russian Вы имеете право получить данную информацию и помощь на вашем языке бесплатно. Для получения помощи звоните в отдел обслуживания участников по номеру, указанному на вашей идентификационной карте. (TTY/TDD: 711) Vietnamese Quý vị có quyền nhận miễn phí thông tin này và sự trợ giúp bằng ngôn ngữ của quý vị. Hãy gọi cho số Dịch Vụ Thành Viên trên thẻ ID của quý vị để được giúp đỡ. (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-[PHONE REDACTED] (TDD: 1- [PHONE REDACTED]) or online at Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.