CHILDREN S HOME SOCIETY OF FLORIDA
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- Doreen Glenn
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1 CHILDREN S HOME SOCIETY OF FLORIDA PLAN HIGHLIGHTS include: Standard Progressive Lenses covered by a $50 copayment Photochromic Lenses (lenses that transition, like Transitions ) covered by a $60 copayment Polycarbonate Lenses for children age 19 and younger at no additional cost An allowance for Eyeglass Frames when members upgrade from the Plan s Frame Selection An allowance for the Contact Lens Examination that is separate from the Contact Lens materials allowance PLAN INFORMATION There will be no restrictions or benefit limitations for pre-existing conditions applied to any employee or their dependents under the Plan. Pre-existing conditions are not applicable to our routine vision benefits. EYE EXAMINATION A comprehensive routine eye examination will be performed once every twelve (12) month benefit period with a $10 copayment. Our network providers perform comprehensive eye examination for the detection of eye disorders and diseases (i.e., diabetic retinopathy caused by diabetes, glaucoma, cataracts, age-related macular degeneration and hypertension) that begins with a visual field test to check peripheral vision. This examination includes depth perception, color vision, glaucoma testing, eye muscle testing and detailed external and internal eye health. The provider will dilate the eyes to examine the retina and assess the overall health of the eyes. Children should begin receiving eye examination, typically around age 3. These examinations will detect color blindness, nearsightedness, farsightedness, astigmatism, amblyopia (lazy eye), strabismus (crossed eyes) and ptosis (drooping of the upper eyelid). EYEGLASSES (Lenses and Frames) All providers will have a Frame Selection available for the Select Plus150 Plan. When a member chooses a frame from this Selection and (single vision, bifocal, trifocal or lenticular) eyeglass lenses, their responsibility is their copayment amount. If they choose additional eyeglass lens options (i.e., ultra violet coating, scratch coating, anti-reflective coating, etc.), their Page 1 of 5
2 responsibility also includes their respective charges. (These lens options/upgrades are calculated at the pre-contracted discounted amounts indicated on the Plan Summary.) If a member elects to choose a frame outside of the Selection, their responsibility is their copayment and the amount in excess of their $150 allowance. The provider will calculate their Eyeglass purchase (using the pre-contracted discounted amounts and subtract the $150 allowance. The difference is the member s responsibility to the provider. CONTACT LENSES - ELECTIVE (in lieu of Eyeglasses) Contact Lenses will be received every twelve (12) month benefit period with a $20 copayment and with a $150 allowance. This benefit is paid only once during the benefit period and must be fully-utilized at the time of purchase. Additional purchases of Contact Lenses beyond the Plan s coverage may be obtained from our network providers utilizing the benefits of our Select Discount Plan at 10-20% discount from the provider s retail charge. CONTACT LENSES - MEDICALLY NECESSARY (in lieu of Eyeglasses) This benefit is limited to Aphakia, Keratoconus or Severe Anisometropia and required preauthorization by Advantica. CONTACT LENS EXAMINATION A Contact Lens Examination will be performed every twelve (12) month benefit period with a $40 allowance. SAFETY GLASSES While it is at the discretion of each provider whether they allow a member to utilize their vision benefits or provide a discount for Safety Glasses, For Eyes Optical has established a Safety Glass Program for Employers to provide Safety Glasses to our members. SUNGLASSES It is at the discretion of each provider whether they allow a member to utilize their vision benefits for Sunglasses. Additional benefits beyond the Plan s coverage for services, Eyeglasses and/or Contact Lenses may be obtained from our network providers utilizing the benefits of our Select Discount Plan at discounts from the providers retail charge. The Select Discount Plan is included at no additional monthly premium rate and with unlimited use of its in-network benefits. Therefore, a member s benefits are never limited and they always have access to eye care services. ADDITIONAL PLAN BENEFITS include: Page 2 of 5
3 For members purchasing Eyeglasses using in-store specials at an in-network provider (i.e., two pair of Eyeglasses for $99), they may submit their paid receipt for the purchase and be reimbursed at their in-network benefit allowance $150 rather than the lower out-ofnetwork reimbursement allocation. Beyond the SP150 Plan benefits, Advantica s Select Discount Plan (SDP) is included with all Plans with no increase in monthly premium rates and with unlimited use of its in--network benefits. Therefore, a member s benefits are never limited and they always have access to eye care services. Mail Order Contact Lenses (at a discount) from For Eyes Optical Company. Since the Program is available for re-supply of Contact Lenses beyond the member s use of their initial funded benefit, there is no limit on order frequency or quantity permitted. For Eyes may be contacted at, EST: Toll free telephone number: Toll free fax number: address: info@foreyes.com LASIK vision correction surgery (at a discount) from TLCVision. A toll free telephone number ( ) is provided and specifically dedicated to Advantica members. MEMBER OUT-OF-NETWORK CLAIMS Advantica processes member claims for out-of-network reimbursements; in-network benefits are covered by a copayment. Our member claims are processed and sent from our Service/Operations Center in Ellicott City, MD. Any communication concerning claim questions will be directed to the member, not the employer. Claims are paid within thirty (30) days of receipt of the completed claim. Advantica will remit all claim reimbursement payments directly to the member at the address indicated on their completed Enrollment Form. Members may obtain the Member Out-Of-Network Reimbursement Request Form from: Our website ( Our Inquiry Service (info@advanticaeyecare.com) or Our Customer Service Department (toll free telephone number ; toll free TTY number ). Members may submit the completed Form, along with their original paid receipt, to our Service/Operations Center at: Page 3 of 5
4 Advantica EyeCare Attention: Claims Payment Department 3290 Pine Orchard Lane Suite D Ellicott City, MD An Explanation Of Benefits Form is generated for member reimbursement of benefits when benefits are received from out-of-network providers. Members may check the status of their submitted claim for reimbursement through: Our Website Inquiry Service at Ask Advantica; Our Inquiry Service at info@advanticaeyecare.com; or Our Customer Service Department (toll free telephone number ; toll free TTY number ). PLAN CONVERSION Vision plan conversion, for members and/or dependents losing membership, may be provided through COBRA Conversion. CUSTOMER SERVICE Our Service/Operations Center is located at: 3290 Pine Orchard Lane Suite D Ellicott City, MD Toll free telephone number: Toll free TTY telephone number: Main telephone number: Fax number: address: info@advanticaeyecare.com Monday through Friday (EST): Saturday: 8:00 a.m. - 6:00 p.m. 10:00 a.m. - 5:00 p.m. All telephone calls are handled in a culturally sensitive manner. We have English and Spanish speaking staff in our Customer Service Department. We are contracted with a Language Line Service to accommodate 140+ other languages. There is no cost to the member for this service. To reach an Page 4 of 5
5 interpreter, call toll free at (Client ID ; press 1 for Spanish; press 2 for all other languages; press 0 for assistance). ID CARDS Within two weeks of enrollment, the member will receive an ID Card for the Vision Plan. If not, please request a replacement ID Card by contacting the customer service department at PROVIDER INFORMATION We require all network providers to be full-service providers; members may obtain their eye examination and materials from the same provider or the eye examination from one provider and the materials from another provider. Our national provider network includes independent and retail optical locations. Retail optical providers include Walmart, Visionworks, Pearle Vision, For Eyes Optical, Sears Optical, JC Penney Optical, Target Optical and others. Providers may be located via: Our interactive website ( Locate Provider Tab; at Directory, select Advantica EyeCare Routine Vision Plans) which enables a member to locate a provider (according to driving distance in relation to the entered zip code) and print a map and directions, within the requested zip code, to a selected provider(s) office. Our Website Inquiry Service. Provider location requests (or other plan-related inquiry) may be posted on our website and a Customer Service Representative will respond (by telephone or ) within twenty-four (24) hours of the inquiry. Our Inquiry Service. Provider location requests (or other plan-related inquiry) may be ed to info@advanticaeyecare.com and a Customer Service Representative will respond (by telephone or ) within twenty-four (24) hours of the inquiry. Our Customer Service Department (toll free at or toll free TTY at ), Monday through Friday from 8:30 a.m. to 6:00 p.m. and Saturday from 10:00 a.m. to 5:00 p.m., EST. Once a provider is located and chosen, telephone the provider to schedule an appointment. When arriving for the scheduled appointment, please present the ID Card. If there is any question regarding eligibility, authorization or plan benefits, please do not continue treatment or leave the provider s office. Please ask the provider to contact our Customer Service Department toll free at for assistance. Page 5 of 5
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Group Vision Care Policy
Group Vision Care Policy Vision Care for Life Group Name: LOYOLA UNIVERSITY MARYLAND Group Number: 12093416 Effective Date: JULY 1, 2012 Certificate of Coverage Provided by: MID-ATLANTIC VISION SERVICE
GROUP VISION CARE PREFERRED PROVIDER ORGANIZATION (PPO) INSURANCE CERTIFICATE
Opticare [[of Utah][Plus Vision]] Dba Opticare Plus Vision A(n) Utah Limited Health Plan Home Office: 1901 West Parkway Blvd. Salt Lake, City, UT 84119 Phone: [800-363-0950] [www.opticareofutah.com] GROUP
VSP Network Providers are those doctors that have agreed to participate in VSP s Choice Network.
EXHIBIT A SCHEDULE OF BENEFITS VSP Choice Plan Plan A GENERAL This Schedule of Benefits lists the vision care services and materials to which Covered Persons of VSP Vision Care, Inc.("VSP") are entitled,
Vision insurance. Benefit Highlights. Additional plan features. How Sun Life s Vision insurance can help
Vision insurance Benefit Highlights For all eligible employees of Alabama-West Florida Conference Of The United Methodist Church, Inc., Policy # 922164 All Eligible Employees (Clergy & Lay) Vision insurance
Vision Coverage. Premiere Vision. Coverage to help keep your vision healthy and your world in focus. SureBridgeInsurance.com CH PR VIS FL 319
Vision Coverage Premiere Vision Coverage to help keep your vision healthy and your world in focus SureBridgeInsurance.com Coverage For Your Vision Care Needs. An annual eye exam is about much more than
Group Vision Care Plan
Group Vision Care Plan Vision Care for Life Group Name: ARKANSAS STATE UNIVERSITY Group Number: 30030164 Effective Date: JANUARY 1, 2012 Evidence of Coverage Provided by: SOUTHWEST VISION SERVICE PLAN,
Group Vision Care Plan
Group Vision Care Plan Vision Care for Life Group Name: XL AMERICA Group Number: 04111032 Effective Date: JANUARY 1, 2014 Evidence of Coverage Provided by: VISION SERVICE PLAN INSURANCE COMPANY 3333 Quality
Blue Shield EPO Plan for Covered California
Blue Shield EPO Plan for Covered California Endorsement Individual and Family Plans An independent member of the Blue Shield Association (Intentionally left blank) Blue Shield of California Pediatric Vision
Social Security Number: Last Name (Subscriber): First Name: DOB: Sex: Home Address: City: State: Zip Code: Date of Birth
DELTA DENTAL Delta Dental Plan of Massachusetts Group Name: MCO H&W Fund MCO Health and Welfare Fund DENTAL/VISION ENROLLMENT FORM & PAYROLL DEDUCTION AUTHORIZATION FAX: 603-647-4668 PH: 800-346-4935 E-MAIL: