ANTHEM VISION PLAN Services Anthem Network Frequency Benefit Out-of-Network ▪ Anthem Well Vision Exam 12 Months $20 Copay Up to $42 Reimbursement Prescription Glasses Plan ▪ 7/1/2021 –6/30/2022 Eyeglass Frames 24 Months $150 Allowance Up to $45 Reimbursement Eyeglass Lenses Provider Search Single Vision 12 Months $25 Copay Up to $40 Reimbursement www.anthem.com Bifocal Vision 12 Months $25 Copay Up to $60 Reimbursement Additional Information Trifocal Vision 12 Months $25 Copay Up to $80 Reimbursement ▪ Benefit Summary Contact Lenses Elective 12 Months $150 Allowance Up to $105 Reimbursement Necessary 12 Months Covered in Full Up to $210 Reimbursement Additional Benefits Additional Lens enhancements and eyewear discounts available from Anthem. 19 19