Dental & Vision
Anthem Dental
Anthem Vision
In-Network
Out-of-Network
Annual Deductible Individual Family
Routine Eye Exam - (once every calendar year)
$75 $225
$10 copay
$42 allowance
Annual Plan Maximum
$1,000
Frames - (once every other calendar year)
Orthodontia Lifetime Maximum (to age 19)
$130 allowance then 20% off any remaining balance
$45 allowance
$2,000
Plan Coinsurance Levels Preventive Services
100% 80% 50% 50%
Standard Plastic Lenses - once every calendar year)
Basic Services Major Services Orthodontia
Single vision (1 pair) Bifocal lenses (1 pair) Trifocal lenses (1 pair)
$20 copay $20 copay $20 copay
$40 allowance $60 allowance $80 allowance
Provider Directory: www.Anthem.com
Contact Lenses - (once every calendar year in lieu of glasses)
Elective Non-Elective
$130 allowance Covered in full
$105 allowance $210 allowance
When you utilize an Anthem Dental Choice Dental provider, you will receive discounts for services provided and the plan will reimburse the maximum allowable benefits. Anthem will pay PPO dentists directly based on their submitted fee or the amount in their local Anthem PPO dentist schedule, whichever is less.
Provider Directory: www.anthem.com Allowances must be used on transaction
Anthem Blue Cross and Blue Shield vision members have access to one of the nation’s largest vision network. Blue View Vision is the only network that gives you the ability to use in- network benefits at 1-800-CONTACTS, or choose a private eye doctor, or go to retail vendors such as LensCrafters®, Sears Optical, Target Optical®, and most Pearle Vision locations.
Page 9 | CREA, LLC | Plan Year 2024
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations , and exclusions set forth in each insurance carrier or provider’s contract.
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