For sales assistance contact Reid Nelson at (602) or
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1 Special Rates for Arizona Eligible Employees Rates Valid as of: 07/1/18 Voluntary Rates, MONTHLY Minimum Participation Required: 2 employees Our vision plans focus on providing the highest quality eye exam while allowing employees the freedom to choose. Vision Plans & Benefit Frequency Exam Only Gold Materials Only 130 PK PLUS Silver Exam + Materials 130 PK PLUS Gold Exam + Materials 130 PK PLUS Exam Materials - Lenses Materials - Frames Every 24 months VCD Complete Eyewear Package Option Vision Care Direct now offers additional ways to save you money and improve the value of your vision plan. By bundling a frame from our VCD Complete Eyewear Value Collection and pairing it with our High Definition lenses with hydrophobic, oleophobic premium anti-reflection coatings we can bring unmatched value and savings. This price advantage comes from providing a package which lowers the cost through purchasing power and lens production efficiency. You ll pay your normal Materials Fee and receive a complete pair of glasses including High Definition lenses, Premium Anti-Reflection and Scratch Coating. If you choose a frame outside of the VCD Complete Eyewear Value Collection there will be an additional fee. Vision Benefit Options from Participating In-Network Providers* (After fees at time of service/up to plan limits) Please check online for VCD Labs provider availability in your area Look for the logo Look for the logo VCD PLUS Complete Eyewear VCD PLUS Package Option Any Frame Member pays exam fee at time of service. Provider Network Exam Comprehensive Exam Flexible Exam Benefit Vision Care Direct Standard VCD Any Frame, any Lens In lieu of a Vision Care Direct Exam (see Benefit Summary on Page 2) Eyewear Member pays materials fee at time of service plus excesses above allowances and add-ons. Standard Single Vision Lens Standard Bifocal Lens Standard Trifocal Lens VCD Complete Eyewear Value Collection frame Any Frame Additional $40 fee applied Premium Progressive Lens * * * * $130 Frame (allowance) Premium Anti-Reflective Coating Resolution Polycarbonate Polycarbonate for Kids Standard VCD, Any Frame Allowance equal to retail price of standard trifocal for dependent children up to age 18 Contact Lenses In lieu of glasses. Professional fees may be extra. Materials fee does not apply for contact lenses. Elective Medically Necessary** $130 allowance $250 allowance Vision Plans & Rates Exam Only Gold Materials Only 130 PK PLUS Silver Exam + Materials 130 PK PLUS Gold Exam + Materials 130 PK PLUS Employee Only $ 7.56 $12.56 $12.52 $15.12 Employee +1 $9.10 $17.10 $17.04 $21.20 Employee/Children $9.72 $18.96 $18.90 $23.70 Employee/Family $13.04 $28.74 $ $36.78 Locate a VCD provider in your area at VCD Labs Complete Eyewear providers will be indicated with this logo: Out-of-network is available at a significantly reduced reimbursement amount. For sales assistance contact Reid Nelson at (602) or reid.nelson@visioncaredirect.com. Vision Care Direct is a Membership Plan not insurance. There is no consumer risk. * For a complete listing of benefits, exclusions and limitations, please reference the benefit summary. ** Medically necessary contacts require prior authorization from your Doctor to the Vision Care Direct Medical Director. Medi cally necessary is defined as 1) Keratoconus; or 2)monocular aphakia and/or binocular aphakia where the doctor certifies contact lenses are m edically necessary. Vision Care Direct 2016 StandardRates.AZ.100+.Vol.4T p.DS (130 PLUS,, )
2 Benefit Summary Description of Benefits dependent on selection at time of enrollment. EXAM BENEFIT (Not applicable on Materials Only plans) Description of Benefits Plan Covers Comprehensive eye-health vision examination includes refraction, and dilation if indicated. 100% after exam fee Member Responsibility Up to $40 after in-network exam fee is deducted Flexible Exam Benefit In the event that a member has a covered eye exam by another plan, the benefit allows the Vision Care Direct exam reimbursement to be used for other services or materials in lieu of a Vision Care Direct eye exam. An explanation will be provided to you by your provider at time of service in regards to the amount and how it was applied to your additional services or materials. MATERIALS BENEFIT (Not applicable on Exam Only plan) Description of Benefits Plan Covers Spectacle Lens 100% for glass or plastic (CR-39) for single vision, bifocal, trifocal (FT25-28) or lenticular Member Responsibility Up to retail price of standard trifocal lens regardless of Rx Overage Polycarbonate for Kids Polycarbonate lenses for dependent children up to age 18 Contact Lens In lieu of frames and spectacle lens (including multi-focal contacts). Allowance applies to fitting fees. Up to maximum listed after innetwork materials fee is deducted: Single: $30 Bifocal: $45 Trifocal: $55 Lenticular: $75 Progressive: $60 100% for dependent children up to age 18 $0 Elective: selected allowance Medically necessary: $250 Materials fee does not apply Up to $80 for elective or medically necessary Frame Allowance Any frame from provider s inventory Up to $35 Progressive lens allowance VCD PLUS Complete Eyewear Package Option (Please check online for VCD Labs provider availability in your area) Spectacle Lens (Single Vision, Bifocal & Acuity 1.50 PAL or equivalent design) Frame 100% for High Definition lenses with hydrophobic, oleophobic premium antireflection coatings Any frame from VCD Labs Value Collection VCD PLUS Complete Eyewear Un-bundled Lens Option (Any Frame) (Please check online for VCD Labs provider availability in your area) Spectacle Lens (Single Vision, Bifocal & Acuity 1.50 PAL or equivalent design) Frame, additional $40 fee applied 100% for High Definition lenses with hydrophobic, oleophobic premium antireflection coatings. Any frame from provider s inventory Up to 15% discount Cost after discount ADDITIONAL BENEFITS - ALL PLANS LASIK/REFRACTIVE BENEFIT Ask your VCD provider for participating providers in your area or call GENERAL LIMITATIONS AND EXCLUSIONS This vision plan is designed for routine eye care and materials expense incurred while the membership is in force. Plan benefits cannot be combined with any other discounts, promotional offers or other advertised specials including, but not limited to, discounts, coupons, or two-for-one materials specials offered by the providers at their individual offices. Members must choose between using their Vision Care Direct benefits or the provider s special offers. Unused benefits do not roll over into next benefit period. We do not provide benefits for the following: Services and materials not included on Benefit Summary including cosmetic Experimental or non-conventional treatment or device items and add-ons Medical or surgical treatment of the eyes other than qualifying discount on Orthoptics or vision training and any associated supplemental testing refractive surgery Subnormal vision aids, non-prescription or aniseikonic lenses Any injury or illness covered by Workers Compensation or similar law Contact lenses for cosmetic enhancement such as changing eye color Two pairs of glasses in lieu of bifocals, trifocals, or progressives except as covered in the Benefit Summary Care for services or materials received while traveling in a foreign country Oversized 61 and above lens or lenses without a detailed receipt in English Additional charge may apply for Rx above +/- 6 sphere and/or 6 cylinder Charges incurred after membership ends CONTACT INFORMATION National Sales & Administration Office Ph: (877) Fax: (602) benefits@integrityoutsource.com Vision Care Direct is a provider-based plan. You can locate a provider at Vision Care Direct 2016 StandardRates.AZ.100+.Vol.4T p.DS (130 PLUS,, )
3 A Vision Plan for Minimum Participation Required: All full time employees Our vision plans center around providing the highest-quality eye exam while allowing employees to select the vision plan that best meets their personal needs. Our plans provide:* Annual comprehensive eye-health examination covered in full Single, bifocal, trifocal or lenticular lenses covered in full Progressive lens benefit for no-line bifocal or trifocals with $180 allowance Choice of contact lenses allowance in lieu of glasses Eye Exam Plan Benefits from Participating In-Network Doctors (After fee at time of service/up to plan limits) Lenses (per pair) Single Bifocal Trifocal Lenticular Progressive Allowance of $180 Contact Lenses Note: contact lens benefit can be chosen in lieu of glasses. Professional fees may be extra. Elective lenses only Allowance of $130 Medically necessary** Allowance of $250 Frame Allowance of $130 Fees at time of service based on plan(s) selected: Exam:.00 Materials:.00 No materials fee for contact lenses Plan Rates - Participation Requirement, MONTHLY Platinum month exam, lens and frame benefit Employee Only Employee +1 Employee/Children Employee/Family $12.54 $17.08 $18.94 $28.70 Locate a VCD provider in your area at Out-of-network is available at a significantly reduced reimbursement amount. For sales assistance contact Reid Nelson at (480) or reid.nelson@visioncaredirect.com. Vision Care Direct is a Membership Plan not insurance. There is no consumer risk. * For a complete listing of benefits, exclusions and limitations, please reference the benefit summary. **Medically necessary contacts require prior authorization from your Doctor to the Vision Care Direct Medical Director. Medi cally necessary is defined as 1) Keratoconus; or 2) monocular aphakia and/or binocular aphakia where the doctor certifies contact lenses are medically necessary. Nelson MADUC 2012 IntegrityOutsource.AZ.Proposal.PR.4T a.DS
4 Benefit Summary Description of Benefits dependent on selection at time of enrollment. EXAM BENEFIT Description of Benefits Plan Covers Member Responsibility Out-of-network Maximum Comprehensive eye-health vision examination includes refraction, and dilation if indicated. MATERIALS BENEFIT Spectacle Lens 100% after exam fee Exam Fee 100% for glass or plastic (CR-39) for single vision, bifocal, trifocal (FT25-28) or lenticular Materials Fee Progressive lens allowance $180 benefit for progressive lens Overage Contact Lens In lieu of frames and spectacle lens (including multi-focal contacts) Allowance applies to fitting fees. Frame Allowance ADDITIONAL BENEFITS LASIK/REFRACTIVE BENEFIT Ask your VCD provider for participating providers in your area or call Elective: selected allowance Medically necessary: $250 Any frame from provider s inventory Materials fee does not apply Up to $40 after in-network exam fee is deducted Up to maximum listed after in-network materials fee is deducted: Single: $30 Bifocal: $45 Trifocal: $55 Lenticular: $75 Progressive: $60 Up to 15% discount Cost after discount Not applicable Up to $80 for elective or medically necessary Up to $35 - not valid on ComputerWear GENERAL LIMITATIONS AND EXCLUSIONS This vision plan is designed for routine eye care and materials expense incurred while the membership is in force. Plan benefits cannot be combined with any other discounts, promotional offers or other advertised specials including, but not limited to, discounts, coupons, or two-forone materials specials offered by the providers at their individual offices. Members must choose between using their Vision Care Direct benefits or the provider s special offers. Unused benefits do not roll over into next benefit period. We do not provide benefits for the following: Services and materials not included on Benefit Summary including cosmetic items and add-ons Orthoptics or vision training and any associated supplemental testing Subnormal vision aids, non-prescription or aniseikonic lenses Contact lenses for cosmetic enhancement such as changing eye color except as covered in the Benefit Summary Oversized 61 and above lens or lenses Experimental or non-conventional treatment or device Medical or surgical treatment of the eyes other than qualifying discount on refractive surgery Any injury or illness covered by Workers Compensation or similar law Two pairs of glasses in lieu of bifocals, trifocals, or progressives Care for services or materials received while traveling in a foreign country without a detailed receipt in English Charges incurred after membership ends CONTACT INFORMATION Claims & Administration Office Ph: (877) Fx: (801) admin@visioncaredirect.com Vision Care Direct is a provider-based plan. You can locate a provider at Nelson MADUC 2012 IntegrityOutsource.AZ.Proposal.PR.4T a.DS
5 By: Arizona Eyecare Alliance To Enroll: Simply complete the form below and return to Vision Care Direct. This is a membership plan, not vision insurance GROUP/ ORGANIZATION Member Application Form CHANGES TO EXISTING PLAN GROUP/ORGANIZATION LOCATION REQUESTED EFFECTIVE DATE EMPLOYMENT STATUS LAST NAME FIRST NAME MIDDLE FULL TIME PART TIME ADDRESS CITY STATE ZIP BIRTHDATE (MM/DD/YY) SEX MALE HOME PHONE WORK PHONE MARITAL STATUS SINGLE MARRIED DIVORCED SEPARATED WIDOWED I am declining coverage at this time. Signature: You must check the plan in which you are enrolling you may enroll in more than one plan 1.Select number of plan/s you are enrolling in: I am enrolling in ONE plan I am enrolling in MULTIPLE plans 2. Select your Plan/s(you may select one or more): Silver Complete PK PLUS: $130 frame allowance Exam Only $130 frame allowance Gold Complete PK PLUS: $130 frame allowance Platinum 130 $130 frame allowance (12 mo Exam, Frame and Lens) Gold Materials Only PK PLUS $130 frame allowance DEPENDENTS TO ENROLL: SPOUSE - LAST NAME FIRST NAME MIDDLE BIRTHDATE (MM/DD/YY) MALE Note: Membership cards are automatically generated when the Member Application Form is processed and entered into the Vision Care Direct system. Please wait until you receive your membership card to seek care. If you require care before your card arrives, please have your VCD doctor logon to to verify eligibility. I understand that Vision Care Direct is a membership plan and not vision insurance. I understand I may make changes for a Qualifying Event (see company policy). I authorize my group to make payroll deductions of monthly contributions from my earnings. As long as I remain employed at my current group, I commit to making all financial contributions required by this program over the period of the contract which is twelve (12) months for all Gold PKPlans and twentyfour (24) months for all Silver PK Plans. Should I leave the group under which I enrolled in the program, I have the opportunity to convert to a VCD Individual Plan. Should I agree to have my plan converted to an individual plan, I will be subject to the terms and conditions under that plan. Enrollee Signature: Date: All VCD contracts in Arizona are owned and governed by Arizona Eyecare Alliance, an Independent Physician Association, in affiliation with Vision Care Direct. National Sales& Administration Office 2178 South 900 East #7, Salt Lake City, UT Toll Free: (877) Vision Care Direct 2015 VCD Enrollment Form
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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
Vision. The Aetna Vision Plan, offers a variety of routine vision care services and supplies.
Vision The Aetna Vision Plan, offers a variety of routine vision care services and supplies. You may enroll in the Plan as a new hire or during annual enrollment. You can change your election if you have
Your Vision PLUS Plan 140. Vision PLUS Plan Summary Chart 141. How the Plan Works 142. What s Covered 143. What s Not Covered 143
Vision PLUS Plan CONTENTS Your Vision PLUS Plan 140 Tips for Finding Information Fast! Click on the above link to see how you can use the document s search function to quickly find the information you
Group Vision Care Plan
Group Vision Care Plan Vision Care for Life Group Name: THE VANGUARD GROUP Group Number: 30069413 Effective Date: JANUARY 1, 2017 EVIDENCE OF COVERAGE Provided by: VISION SERVICE PLAN INSURANCE COMPANY
Comparison of Voluntary Vision Rates
Coverage Employee Only Employee and Spouse Employee and Child(ren) Family Comparison of Voluntary Vision Rates MetLife $9.60 $15.39 $17.39 $25.95 Dearborn $6.20 $11.80 $12.43 $18.28 Diff/mo $3.40 $3.59
Premiere Vision. Vision Coverage for Seniors
Vision Coverage for Seniors Premiere Vision Get vision coverage that can offer you savings on vital eye care, including exams and prescription glasses, benefits that are not included in your Original Medicare
Premiere Vision. Vision Coverage for Seniors
Vision Coverage for Seniors Premiere Vision Get vision coverage that can offer you savings on vital eye care, including exams and prescription glasses, benefits that are not included in your Original Medicare
Vision Program. Effective January 1, Introduction How the Program Works... 2
Vision Program Effective January 1, 2011 Introduction... 2 How the Program Works... 2 A Snapshot of Your Vision Coverage Through Vision Service Plan (VSP)... 3 What the Program Covers... 3 Using VSP Network
Group Vision Care Plan
Group Vision Care Plan Vision Care for Life EVIDENCE OF COVERAGE & DISCLOSURE FORM Provided by: VISION SERVICE PLAN 3333 Quality Drive, Rancho Cordova, CA 95670 (916) 851-5000 (800) 877-7195 THIS EVIDENCE
HumanaVision Voluntary Vision Care Plan
HumanaVision Voluntary Vision Care Plan TEXAS REPUBLIC HEALTH RESOURCES 1. Choose your exam/material 1 copay: $10/$15 $15/$15 $15/$20 $20/$20 Approximate retail value: 2. Choose your wholesale frame allowance:
USI Affinity Vision Summary
Rate Summary USI Affinity Vision Summary USI Affinity Vision area rates Low Plan M100-10/10 Member Member+ Spouse Member+ Child(ren) Family Area 1 $9.34 $18.71 $15.84 $26.13 Area 2 $9.46 $18.95 $16.04
STEPS YOU ARE REQUIRED TO TAKE TO CONTINUE COVERAGE
Congratulations on your decision to retire! W e are pleased to provide benefit plan information for retirees for the 2017 calendar year. W e encourage you to review this communication and the enclosed
Individual Vision Rider Indemnity Plan
Underwritten by SafeHealth Life Insurance Company Individual Vision Rider Indemnity Plan SH IND VIS R 1 The Policyholder is: Policy Number: SAFEHEALTH LIFE INSURANCE COMPANY Post Office Box 30930 Laguna
Fidelity Security Life Insurance Company agrees to pay the benefits provided by the Policy in accordance with its terms and conditions.
F I D E L I T Y S E C U R I T Y L I F E I N S U R A N C E C O M P A N Y 3130 Broadway Kansas City, Missouri 64111-2406 Phone 800-648-8624 A STOCK COMPANY (Herein Called the Company ) POLICY NUMBER: POLICYHOLDER:
Group Enrollment Processing. In order to ensure proper processing of your applications, please read the following instructions carefully.
Dergalis ASSOCIATES Group Enrollment Processing In order to ensure proper processing of your applications, please read the following instructions carefully. 1) Once you have selected the plan(s) in which
Group Vision Care Policy
Group Vision Care Policy Vision Care for Life Group Name: AVNET, INC. Group Number: 30009825 Effective Date: JANUARY 1, 2013 Certificate of Coverage Provided by: VISION SERVICE PLAN INSURANCE COMPANY 3333
SUMMARY PLAN DESCRIPTION
TESORO CORPORATION VISION PLAN SUMMARY PLAN DESCRIPTION As of January 1, 2016 1 Table of Contents PARTICIPATION...3 COVERAGE FOR YOUR DEPENDENTS...3 DOMESTIC PARTNER COVERAGE...3 QUALIFIED MEDICAL CHILD
Deductible then 50% co-insurance Professional Services Primary care provider (PCP) Office and home visits
Provider Network: BrightPath Medical Schedule of Benefits BrightIdea Value Silver 3600 (87) Annual Deductible Per Person, Per Calendar Year Per Family, Per Calendar Year Participating Providers $1,100
Vision Benefit Summary
Cowan Systems, LLC Effective: January 01, 2015 Group Number: 00507869 Vision Benefit Summary About Your Benefits: Eye care is a vital component of a healthy lifestyle. With vision insurance, having regular
If you use an IN-NETWORK provider (Member cost) $10 Up to $39. Up to $55 10% off retail. 20% off balance over $130
SGB0151A Humana Vision 130 TEXAS Vision care services Exam with dilation as necessary Retinal imaging 1 Contact lens exam options2 Standard contact lens fit and follow-up Premium contact lens fit and follow-up
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 Care Plan Highlights
Vision Care Plan Highlights General Information This Highlights document provides a brief overview of the key features of the Plan. Detailed program provisions, including coverage and coverage amounts,
DeltaVision VISION... Insured vision plans from Delta Dental of Arizona. An Integral Part of the Big Picture
DeltaVision Insured vision plans from Delta Dental of Arizona VISION... An Integral Part of the Big Picture DeltaVision is offered through Canyon Insurance Services, Inc., a wholly owned subsidiary of
Your Vision Benefits Indian River State College
Your Vision Benefits Indian River State College SGB0153A Humana Vision 100 FLORIDA Vision care services Exam with dilation as necessary Retinal imaging 1 Contact lens exam options2 Standard contact lens
KEY GROUP VISION INSURANCE
KEY GROUP VISION INSURANCE KEY GROUP VISION INSURANCE BENEFITS FOR EMPLOYEES THAT BENEFIT EMPLOYERS Underwritten by Companion Life Insurance Company Administered by Key Benefit Administrators WHY A VISION
Group Vision Care Plan
Group Vision Care Plan Vision Care for Life EVIDENCE OF COVERAGE & DISCLOSURE FORM Provided by: VISION SERVICE PLAN 3333 Quality Drive, Rancho Cordova, CA 95670 (916) 851-5000 / (800) 877-7195 January
2019 Annual Open Enrollment Form for Dental Coverage
DENTAL ENROLLMENT *INSdental* CHICAGO REGIONAL COUNCIL OF CARPENTERS WELFARE FUND RETIREE PLAN OF BENEFITS Fax: (312) 951-3986 Email: pension@crccbenefits.org 12 East Erie Street, Attn: Retirement Benefits
Hillsboro/Durham/Lehigh USD #410. Benefits Information. For Plan Year September 1, 2017 to August 31, 2018
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Welcome to VSP Vision Care Signature Plan.
Welcome to VSP Vision Care Signature Plan. SCHEDULE OF BENEFITS Benefit Copay Frequency WellVision Exam Once every 12 months Prescription Glasses $5.00 for exam and glasses Lenses Once every 12 months
Vision Benefit Summary
PENSKE TRUCK LEASING Benefit Plan Year 2017 Vision Benefit Summary Customer Service and Provider Locator: (800) 638-3120 myuhcvision.com UnitedHealthcare vision has been trusted for more than 50 years
Service Participating Providers: Non-participating Providers:
Provider Network: SmartHealth Network PSGOOC.MT.SG.0115 Medical Benefit Summary SmartHealth Value Silver 3000 Annual Deductible Per Person, Per Calendar Year Per Family, Per Calendar Year Participating