vision

Description

Chipotle provides you two vision plan options to choose from. Both plans help with the cost of exams and glasses or lenses. The Buy-Up option provides an increased allowance for materials and a lower copay for exams.

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Vision Comparison Chart

Plan Details

Vision Base Plan
In-Network

Vision Buy-Up Plan
In-Network

Eye Exam

Once every 12 months; Includes retinal imaging, up to provider limits

$10 copay
$5 copay

Standard Contact Lens Fit & Follow-Up

Up to $40 copay
Up to $40

Frames

Once every 12 months

$0 copay, $130 allowance
20% discount on balance over $130
$0 copay, $300 allowance
20% discount on balance over $300

Standard Plastic Lenses

Once every 12 months; Covers single, bifocal, trifocal, lenticular, and standard progressive lenses

$20 copay
$0 copay

Contact Lenses (instead of glasses)

Medically Necessary

$0 copay
$0 copay

Conventional

$130 materials allowance
15% off balance over $130
$300 materials allowance
15% off balance over $300

Disposable

$300 materials allowance
$300 materials allowance

Your Bi-Weekly Cost for Coverage

You

$0.00
$4.29

You + Spouse/Domestic Partner

$2.11
$10.68

You + Child(ren)

$1.69
$9.39

You + Family

$3.68
$15.21

For additional information including out-of-network coverage, visit CultivateMe.

Anthem ASO

Phone: 855-653-4066
Web: anthem.com
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This guide provides a summary of our benefits plans. Official plan and insurance documents govern your rights and benefits under each plan. For more details about your benefits, including covered expenses, exclusions, and limitations, please refer to the individual Summary Plan Description (SPD), plan document, or certificate of coverage for each plan. If any discrepancy exists between this guide and the official plan documents or contracts, the plan documents and contracts will prevail.
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