2017 Open Enrollment All Employees Required to Enroll November 2 nd 17 th

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1 2017 Open Enrollment All Employees Required to Enroll November 2 nd 17 th 2017 Medical & Dental Open Enrollment Enclosed, Learn About 2 Enrollment Instructions 3 Medical Insurance 4 Medical Reimbursement & Health Savings Accounts 7 Dependent Daycare 8 Critical Illness 9 Accident Supplement 10 Short-term Disability 11 Long-term Disability 12 Universal Life with LTC 13 Term Life Insurance 14 Dental Employees earning fulltime benefits are eligible to enroll and/or make changes to medical and dental plan elections.* There are no plan design or rate changes for the plans currently offered; however a 4 th plan option has been made available. Addition of Anthem s Three Tiered (PPO Plan) with Hendricks Regional Health No co-pays for primary care when you use HRH providers. This may save you money, if you exclusively use HRH providers. If you select this plan, you still have access to the Anthem. For full details, the Summary of Benefits is posted in the Human Resources section of the Avon Community Schools website. Short-term Disability Open Enrollment 15 Vision Insurance Information pamphlet produced by Steele Benefit Services For the first time in several years, coverage is available with no health questions (guarantee issue) for all eligible employees. There is a new provider OneAmerica. The rates and design of the plan are unchanged. NEW! Choose your Enrollment Method Online Employee Self Service Sign-up to meet with a Steele Representative Prefer Online Employee Self Service? 1. Navigate to trustmark.benselect.com 2. Enter your social security # as prompted (no dashes) 3. Enter your PIN # (last four of ssn and your birth year: i.e. ssn of and birthdate of 3/1/1983; your PIN is ) 4. Follow the on screen instructions to make your benefit elections for Sign for your benefits by re-entering your PIN when finished Prefer to set an individual appointment with a Steele Benefits representative? An onsite representative will continue to be made available to employees.

2 2017 Open Enrollment All Employees are Required to Enroll November 2 nd - 17 th CHOOSE YOUR ENROLLMENT METHOD 1 Enroll On-Site! Available during open enrollment only. As usual, a Steele representative will spend time in your building. Sign-up for an individual appointment, if you choose. 2 Enroll Yourself Online! Instructions: a) Navigate to b) enter your social security number (with no dashes), and c) enter your PIN to login. Your PIN is Last 4 of your SSN and Your Birth Year. For Example: SSN is and Birthdate is 3/1/1983 Your PIN is À ENROLLING MADE EASY! The enrollment schedule for individual enrollment day(s) is outlined on the next page. Make an appointment on the signup sheet, and Steele will help you through your enrollment. This enrollment process is for all 2017 insurance benefits. Enroll in any of the benefits you may be eligible for including: *Medical, *Dental, Vision, Short-term Disability, Long-term Disability, Term Life, Permanent Life, Accident, Critical Illness, and Flexible Spending Accounts. * Only employees earning fulltime benefits are eligible to enroll and/or make changes to medical and dental plan elections.*

3 ANTHEM MEDICAL INSURANCE BENEFITS Reference the enrollment system or the Avon Community Schools website for premiums. Blue Access PPO Blue Access PPO - Blue Access CDHP 1 Blue Access CDHP 2 Hendricks Regional Health- 3 Tier Covered Benefits Non- Tier 1: HRH Tier 2: Anthem Tier 3: Non- Non- Non- Deductible (Single/Family) $500, $1000 $1000, $2000 $500, $1000 $750, $1500 $1000, $2000 $3000, $6000 $6000, $12000 $6000, $12000 $12000, $24000 Out-of-Pocket Limit (Single/Family) $3000, $6000 $6000, $12000 $3000, $6000 $3500, $7000 $6000, $12000 $3000, $6000 $12000, $24000 $6000, $12000 $24000, $48000 Preventative Care Services 100% 50% 100% 100% 50% 100% 30% 100% 30% Primary Care Physician $25 50% $0 $30 50% Specialty Care Physician $25 50% $25 $30 50% 30% 30% Emergency Room Services $150 $150 $150 $250 50% 0% 0% Urgent Care Services $75 50% $75 $75 50% 30% 30% Inpatient and Outpatient 20% 50% 20% 20% 50% 30% 30% Professional Services Inpatient Facility Services 20% 50% 20% 20% 50% subject to 30% subject to 30% deductible, deductible, Other Outpatient Services 20% 50% 20% 20% 50% then 30% then 30% Outpatient Therapy $25 50% $0 $25 50% covered at 30% covered at 30% Services 100% 100% Behavioral Health 20% 50% 20% 20% 50% 30% 30% Prescription Drugs Retail Pharmacy Anthem Rx Direct Mail Pharmacy Lifetime Maximum for Medical $10, $30, $60 $20, $75, $150 50%, minimum $60 not covered $10, $30, $60 $20, $75, $150 $10, $30, $60 $20, $75, $150 50%, minimum $60 not covered Descriptions in this pamphlet may be incomplete. Consult certificates and/or summary of benefit for full list of benefits and exclusions. 30% 30%, if covered not covered 30% 30%, if covered not covered Unlimited Unlimited Unlimited Unlimited Unlimited Unlimited Unlimited Unlimited Unlimited

4 Medical Reimbursement WHAT IS TRADITIONAL MEDICAL REIMBURSEMENT? The Medical Flexible Spending Account (MFSA) is a program that allows you to use untaxed money for out-of-pocket medical, dental, and vision expenses. Examples include co-pays, prescription meds, glasses, contacts, and dental work. A Traditional Medical Reimbursement program is not available for those who will have 2017 CONTRIBUTIONS to a Health Savings Account (HSA). However, NEW this year, a Limited Purpose FSA (LPFSA) is available for dental, vision and orthodontia expenses only. See additional detail below. HOW DOES IT WORK? 1. Come up with an amount that you and your family will spend on eligible expenses for the year (for example, $1000 for the year). 2. Complete an application for medical reimbursement and make your annual election (in this case, $1000). 3. The $1000 election is divided by your number of payrolls, and an even amount comes from each paycheck. 4. Prior to the start of the plan year, you will receive a MasterCard. 5. During the plan year, use the MasterCard for eligible expenses. 6. You can spend faster than your paycheck is funded (in this case, you can spend your $1000 even before it comes out of your paycheck) 7. Each contribution into your account through your payroll reduces your taxable income and saves you money. 8. Be sure to spend all your Medical Reimbursement money during the plan year, because you lose any money that you do not spend. WHAT DO I NEED TO KNOW FOR THIS YEAR S ENROLLMENT? IRS REGULATIONS restrict household participation in a traditional Medical Reimbursement FSA if you, your spouse or an employer is contributing to your HSA at any point during IF CONTRIBUTIONS WILL BE MADE TO YOUR HSA IN 2017, you may enroll in a Limited Purpose FSA (LPFSA). Eligible LPFSA expenses are those related to only: Dental Vision Orthodontia ANNUAL MAXIMUM FOR LPFSA and MFSA: $2,550. The Flexible Spending Account plan year will begin January 1 st each year. Be conservative with the amount you put into your plan in order to make sure you can spend it by December 31, If you have funds left in the account after 12/31, utilize the grace period. See detail below. ****Your FSA includes a (75 day) grace period. The grace period allows you to continue incurring expenses 75 days after 12/31. Under the grace period, all funds must be incurred by 3/16. You may use your card as normal to access grace period funds (until 3/15). Pre-taxed- Plan Administration Fee: $1.98 (24 PAYS) OR 2.97 (16 PAYS)

5 Medical Flexible Spending Accounts & Health Savings Accounts Some of the most common uses include: Medical Insurance deductible Medical Insurance coinsurance Medical Co-pays Dental Work Orthodontics Vision-related out-of-pocket expense Prescription medications Debit Cards are available, making the section 125 claims process easier Features of Your Plan Access Flexible Spending Account contributions with the convenience of MasterCard Use your funds for anyone in your household Not required to participate in the health plan in order to open a flexible spending account. Illustration - Flexible Spending Account or Health Savings Account Sample Item Annual Cost Tax Saving Sample Savings Ms. Smith Prescriptions $ % $ Mr. Smith Prescriptions $ % $ Junior Smith's Glasses $ % $ Junior Smith's Braces $ 1, % $ Mr. Smith Dental Work $ % $ Ms. Smith Contact Lenses $ % $ Miscellaneous $ % $ Totals $ 2, % $ Must have a qualified high deductible health plan in order to contribute to a health savings account Be careful unused funds are forfeited under the use-or-lose rules for Flexible Spending Accounts Health Savings Accounts monies roll over from year to year. SOME THINGS TO REMEMBER ABOUT FLEXIBLE SPENDING ACCOUNTS (MEDICAL REIMBURSEMENT All expenses that you claim during this plan year must be incurred between January 1, 2017 and December 31, However, your plan includes a grace and run-out feature: Grace Period: (75 days extension)- Simply offers you some extra time to spend your FSA monies. Use your card as normal to access funds from the previous plan year through March 15th. Run-out Period: (15 days past grace period)- Cut off for filing paper claims for the previous plan year. If your claim is not submitted and received before March 29th, you will forfeit your remaining balance. Paper claim forms can be printed from:

6 ELIGIBLE EXPENSES FOR FLEXIBLE SPENDING ACCOUNTS AND HEALTH SAVINGS ACCOUNTS MEDICAL TREATMENTS Acupuncture Ambulance Chiropractic Diathermy Electric shock Hearing services Hydrotherapy (water treatments), Whirlpool baths Injections and Insulin treatments Lasix Surgery Navaho healing ceremonies ("sings") Nursing Organ transplant Pre-natal and post-natal treatments Psychotherapy Radium therapy Sterilization Ultra-violet ray treatments Vasectomy X-ray treatments MEDICINE AND DRUGS Prescription medication Contact lenses solutions LABORATORY EXAMINATION AND TESTS Blood tests Cardiographs Metabolism tests Spinal fluid tests Sputum tests Stool examination, urine analysis X-ray examinations DENTAL SERVICES Cleaning of teeth, dental x-rays, filling of teeth Extraction of teeth, gum treatments Oral surgery MISCELLANEOUS Alcoholic inpatient care tests Birth control pills Convalescent home (for medical treatment only) Drug treatment center (for inpatient care cost only) Sunscreen (SPF 30+) PROFESSIONAL SERVICES Chiropodist, Chiropractor Christian Science practitioner Dermatologist Dentist Gynecologist, Obstetrician Neurologist Oculist Optician, Optometrist Orthopedist Osteopath Pediatrician Physician Physiotherapist Podiatrist Psychiatrist, Psychoanalyst, Psychologist Registered nurse Surgeon EQUIPMENT AND SUPPLIES Abdominal supports Ambulance hire Arches Artificial teeth, eyes Back supports Braces Contact lenses, eyeglasses Crutches Elastic hosiery Fluoridation unit in the home Hearing aids and Heating devices Invalid chair or reclining chair, if prescribed by a doctor Iron lung Orthopedic shoes Repair of special telephone equipment for the deaf Sacroiliac belt Splints Truss HOSPITAL SERVICES Anesthetist, Oxygen mask or a tent Hospital bills, operating room charges, Vaccines X-ray technician

7 Dependent Daycare Does your family incur daycare expense? If so, it may make sense for you to setup a dependent daycare reimbursement flexible spending account. Candidates for dependent daycare flexible spending accounts are employees who: Have a household taxable income between $39.1k or higher. You may participate with a lower household income as well, but may want to discuss with your representative whether a dependent daycare account makes sense for you. Your household may claim up to $5,000 per calendar year in dependent daycare expense. Unlike medical reimbursement accounts, participants in a dependent daycare account must have monies deducted from their paycheck before they are eligible for reimbursement. The IRS does not allow employers to pre-fund a dependent daycare account (note: that is a difference from the medical reimbursement accounts). Monies contributed to a dependent daycare flexible spending account automatically reduce your taxable income do not claim these dollars on your end of the year taxes. Your daycare provider is not required to be licensed, however must claim the daycare dollars on their taxable income. Monies paid for tuition (i.e. pre-school) are not eligible. Debit Cards are available, making the section 125 claims process easier If you have daycare expense and a household income in excess of $39.1k per year, a dependent daycare account may make sense Features of Your Plan Access Flexible Spending Account contributions with the convenience of MasterCard SOME THINGS TO REMEMBER This plan year is January 1 December 31, 2017 Pre-tax up to $5000 per year for dependent daycare expenses per household All expenses that you claim during this plan year must be incurred between January 1, 2017 and December 31, 2017 Not required to participate in the health plan in order to open a flexible spending account Be careful unused funds are forfeited under the use-or-lose rules Plan Administration Fee: $1.98 (24 pays) or $2.97 (16 pays). Participate in both Medical Reimbursement and Dependent Daycare Account? There is only ONE Plan Administration Fee.

8 Critical Illness Insurance Worry less. Critical Illness benefits offer money to help you focus on recovery in the event of serious illness. Lincoln s Critical Illness pays you a lump sum-cash benefit for you to use however you wish (deductible, copayments, car payments, utilities, food, childcare, rent or mortgage, etc). Covered Illnesses Heart Category Cancer Category -Heart Attack (100%) -Invasive Cancer (100%) -Heart Transplant (100%) -Cancer In Situ (25%) -Stroke (100%) -Benign Brain Tumor (25%) -Arteriosclerosis (10%) -Bone Marrow Transp. (25%) -Aneurysm (10%) Organ Category Quality of Life Category -End Stage Renal -ALS/Lou Gehrig s Disease (100%) Failure (100%) -Advanced Alzheimer s Disease (100%) -Major Organ Transplant -Advanced Parkinson s Disease (100%) (excluding heart) (100%) -Advanced MS (25%) -Acute Respiratory Distress -Loss of Sight, Hearing, or Speech (25%) Syndrome (25%) NO Health Questions this Enrollment! EMPLOYEE SPOUSE CHILDREN Guarantee Issue! Benefit Features: Employee, Spouse, Children Coverage -Employee: $20,000 Spouse: $20,000 Children: $5,000/$10,000 Includes Annual Wellness Benefit -$50 annual benefit for insured Employee or Spouse Ability to Customize the Benefit Volume Benefit may Payout Multiple Times for Occurrences in Separate Categories -Reference the Lincoln brochure/benefit summary for specific details Employee Rate Examples: $10,000 Benefit Non-Tobacco *Price is illustrated per pay- rate is based off age at initial enrollment (Spouse rates are comparable) $ $ $ $16.37

9 Accident Insurance Accidents happen all of the time and the out-of-pocket costs that may accompany a resulting injury like fracturing your wrist or dislocating your shoulder can add up quickly. Accident insurance pays you a benefit if you're hurt as a result of a covered accident. This extra money can help protect you from the financial impact of injury. Did You Know 66% of all accidents occur off the job More than 23.8 million injuries required medical attention in 2003 Source: National Safety Council, Injury Facts, Covers Accidents including Sports Injuries Highlight of Benefits Ambulance Benefit Air Ambulance Emergency Room Treatment Accident Follow-up Treatment Initial Hospitalization Hospital Confinement Intensive Care Benefit Physical Therapy Benefit Lodging Transportation Appliance Prosthesis Accidental Death Fractures, Lacerations, etc. Individual Single Parent Employee+Spouse Family Benefits $200 $1,000 $200 $100 $2,000 $400/day $600/day $50/treatment $200/day $475/trip $200 Up to $2,000 $50,000 l-- Based on a benefit schedule l $3.82/week $7.35/week $5.56/week $9.08/week

10 Short-term Disability What is the Short-term Disability? The Short-term Disability is a benefit that makes sure you get paid, even if you are unable to work. It pays in addition to sick pay. If I enroll, how much will I get paid if I am disabled? Choose from benefit levels between $300/ month and $5,000/ month, not to exceed 2/3 of your normal pay. This year, guaranteed approval of coverage up to 2/3 of your pay, capped at a $2,000 monthly benefit. What are some common types of incidents that would cause me to be disabled? Sicknesses or injuries including back issues, joint issues, muscle issues, and sicknesses including pneumonia, cancer, diabetes, etc. Maternity is also a covered benefit. What are the limitations? Consult the Summary of Benefits for a full list of limitations. Two of the most common limitations are: 1) Pre-existing conditions (conditions treated between and ) are excluded for the first policy year ( through ). 2) Monthly benefits are reduced by amounts received through workers compensation for on the job injury. The minimum monthly benefit amount payable under the policy is 25% of the gross monthly benefit, regardless of the amount of income you receive from other sources. 30% of all people ages 35 to 65 will suffer a disability for at least 90 days Disability Fact Book, in 7 people ages 35 to 65 will become disabled for 5 years or more Disability Fact Book, 2001 How much does it cost? * Increments available between $300/month and $5000/month. These are examples based on specific benefit amounts. COST BASED ON 24 PAYROLLS 48% of all home foreclosures were due to a disability Eastbridge Consulting Group, March 2000 Benefit Amount Benefits after 7 days Benefits after 14 days $500/month $8.23 $7.05 $1000/month $16.45 $14.10 $1500/month $24.68 $21.15 $2000/month $32.90 $28.90 Benefit amounts range from $300/month to $5000/month up to 67% of salary Consult the Summary of Benefits for details

11 Long-term Disability What is the Long-term Disability? The Long-term Disability is a benefit that makes sure you get paid, even if you are unable to work. It pays in addition to sick pay. If I enroll, how much will I get paid if I am disabled? Choose from benefit levels between $300/ month and $5,000/ month, not to exceed 2/3 of your normal pay. This year, guaranteed approval of coverage up to 2/3 of your pay, capped at a $5,000 monthly benefit. What are some common types of incidents that would cause me to be disabled? Sicknesses or injuries including back issues, joint issues, muscle issues, and sicknesses including pneumonia, cancer, diabetes, etc. 30% of all people ages 35 to 65 will suffer a disability for at least 90 days What are the limitations? Consult the Summary of Benefits for a full list of limitations. common limitations are: Two of the most Disability Fact Book, ) Pre-existing conditions (conditions treated between and ) are excluded for the first policy year ( through ) 2) Monthly benefits are reduced by amounts received through workers compensation, social security, and State Teachers Retirement System. The minimum monthly benefit amount payable under the policy is 25% of the gross monthly benefit, regardless of the amount of income you receive from other sources. How much does it cost? * Increments available between $300/month and $5000/month. These are examples based on specific benefit amounts. COST BASED ON 24 PAYROLLS Benefit Amount Benefits after 180 days $500/month $4.23 $1000/month $ in 7 people ages 35 to 65 will become disabled for 5 years or more Disability Fact Book, % of all home foreclosures were due to a disability Eastbridge Consulting Group, March 2000 $1500/month $12.68 $2000/month $16.90

12 Life Insurance including optional addition of Long-term Care QUOTES PERSONALIZED WITH YOUR BENEFIT REPRESENTATIVE DURING YOUR MEETING EMPLOYEE, SPOUSE, CHILDREN & GRANDCHILDREN COVERAGE AVAILABLE WHAT IS UNIVERSAL LIFE INSURANCE (UL)? Universal Life Insurance is Flexible Permanent Life Insurance that you can take with you if you leave the school. The cost will not increase when you retire, leave the corporation, or continue to age. WHO SHOULD CONSIDER SIGNING UP? Employees & their spouses that do not already have permanent life insurance. Children and Grandchildren are also eligible. HOW MUCH LIFE INSURANCE CAN I PURCHASE? The death benefit will depend on your age and whether you are a smoker. You may purchase up to $300,000 on employee or spouse, although the most common benefit amounts range from $10,000 to $125,000 WHAT IS THIS LONG-TERM CARE BENEFIT I KEEP HEARING ABOUT? Persons who have the long-term care benefit may use up to 4% of the death benefit each month for long-term care expenses. Therefore, if you have a $100,000 death benefit up to $4,000 per month can be used for long-term care expenses.

13 Term Life Insurance QUOTES PERSONALIZED WITH YOUR BENEFIT REPRESENTATIVE DURING YOUR MEETING EMPLOYEES HAVE AN OPPORTUNITY TO ENROLL GUARANTEE ISSUE UPON HIRE IF YOU MISS YOUR OPPORTUNITY TO ENROLL AT HIRE, YOU MAY ENROLL LATER SUBJECT TO INSURABILITY EMPLOYEE, SPOUSE, & CHILDREN COVERAGE AVAILABLE WHAT IS TERM LIFE INSURANCE? Term Life Insurance is life insurance that is available for a specific amount of time. At Avon, the policy does not expire but the cost is based on your current age and does increase as you get older. To account for your changing life needs, you may apply to increase (with medical underwriting questions) or decrease coverage as your insurance needs fluctuate. WHO SHOULD CONSIDER SIGNING UP? Employees & their spouses with dependent children or with financial obligations. HOW MUCH LIFE INSURANCE CAN I PURCHASE? Employees may purchase up to 5X salary. WHAT IS BETTER, TERM LIFE INSURANCE OR UNIVERSAL LIFE INSURANCE? Both serve a purpose. Term life insurance is meant to maximize the amount of coverage for the premium right now. Universal Life is designed to give you a premium amount you will be able to afford for your entire life. In general, families with children or temporary debt obligations would be wise to carry term life. Alternatively or additionally, you may want Universal Life Insurance to provide you coverage during your retirement or to assist with long-term care expenses.

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15 WELCOME TO BLUE VIEW VISION! Good news your vision plan is flexible and easy to use. This benefit summary outlines the basic components of your plan, including quick answers about what s covered, your discounts, and much more! Custom Group: Avon Community Schools High Plan Effective Date: 01/01/2017 Blue View Vision SM Your Blue View Vision network Blue View Vision offers you one of the largest vision care networks in the industry, with a wide selection of experienced ophthalmologists, optometrists, and opticians. Blue View Vision s network also includes convenient retail locations, many with evening and weekend hours, including CONTACTS, LensCrafters, Sears Optical SM, Target Optical, JCPenney Optical and most Pearle Vision locations. Best of all when you receive care from a Blue View Vision participating provider, you can maximize your benefits and money-saving discounts. Out-of-network: If you choose to, you may receive covered benefits outside of the Blue View Vision network. Just pay in full at the time of service, obtain an itemized receipt, and file a claim for reimbursement of your out-of-network allowance. In-network benefits and discounts will not apply. YOUR BLUE VIEW VISION PLAN AT-A-GLANCE VISION PLAN BENEFITS IN-NETWORK OUT-OF-NETWORK Routine eye exam once every 12 months $10 copay, then covered in full $42 allowance Eyeglass frames Once every 24 months you may select an eyeglass frame and receive an allowance toward the purchase price Eyeglass lenses (Standard) Once every 12 months you may receive any one of the following lens options: Standard plastic single vision lenses (1 pair) Standard plastic bifocal lenses (1 pair) Standard plastic trifocal lenses (1 pair) $150 allowance, then 20% off any remaining balance $20 copay, then covered in full $20 copay, then covered in full $20 copay, then covered in full $45 allowance $40 allowance $60 allowance $80 allowance Eyeglass lens enhancements When obtaining covered eyewear from a Blue View Vision provider, you may add any of the following lens enhancements at no extra cost. Lenses (for a child under age 19) Lenses (Adults) Standard Polycarbonate (for a child under age 19) Factory Scratch Coating $0 after eyeglass lens copay $20 after eyeglass lens copay $0 after eyeglass lens copay $0 after eyeglass lens copay No allowance on lens enhancements when obtained out-of-network Contact lenses once every 12 months Prefer contact lenses over glasses? You may choose contact lenses instead of eyeglass lenses and receive an allowance toward the cost of a supply of contact lenses. Elective Conventional Lenses; or Elective Disposable Lenses; or Non-Elective Contact Lenses Your contact lens allowance can only be applied toward the first purchase of contacts you make during a benefit period. Any unused amount remaining cannot be used for subsequent purchases made during the same benefit period, nor can any unused amount be carried over to the following benefit period. $140 allowance, then 15% off any remaining balance $140 allowance (no additional discount) Covered in full $105 allowance $105 allowance $210 allowance EXCLUSIONS & LIMITATIONS (not a complete list) Combined Offers. Not combined with any offer, coupon, or in-store advertisement. Excess Amounts. Amounts in excess of covered vision expense. Sunglasses. Sunglasses and accompanying frames. Safety Glasses. Safety glasses and accompanying frames. Not Specifically Listed. Services not specifically listed in this plan as covered services. Lost or Broken Lenses or Frames. Any lost or broken lenses or frames are not eligible for replacement unless the insured person has reached his or her normal service interval as indicated in the plan design. Non-Prescription Lenses. Any non-prescription lenses, eyeglasses or contacts. Plano lenses or lenses that have no refractive power. Orthoptics. Orthoptics or vision training and any associated supplemental testing.

16 OPTIONAL SAVINGS AVAILABLE FROM IN-NETWORK PROVIDERS ONLY In-network Member Cost (after any applicable copay) Retinal Imaging - at member s option can be performed at time of eye exam Not more than $39 Eyeglass lens upgrades When obtaining eyewear from a Blue View Vision provider, you may choose to upgrade your new eyeglass lenses at a discounted cost. Eyeglass lens copayment applies. Standard Polycrbonate (Adults) Tint (Solid and Gradient) UV Coating Progressive Lenses 1 Standard Premium Tier 1 Premium Tier 2 Premium Tier 3 Anti-Reflective Coating 2 Standard Premium Tier 1 Premium Tier 2 Other Add-ons and Services $40 $15 $15 $65 $85 $95 $110 $45 $57 $68 20% off retail price Additional Pairs of Eyeglasses Anytime from any Blue View Vision network provider Complete Pair Eyeglass materials purchased separately Eyewear Accessories Items such as non-prescription sunglasses, lens cleaning supplies, contact lens solutions, eyeglass cases, etc. Contact lens fit and follow-up A contact lens fitting and up to two follow-up visits are available to you once a comprehensive eye exam has been completed. Standard contact lens fitting 3 Premium contact lens fitting 4 40% off retail price 20% off retail price 20% off retail price Up to $55 10% off retail price Conventional Contact Lenses Discount applies to materials only 15% off retail price Laser vision correction surgery LASIK refractive surgery Discount per eye For more information, go to anthem.com/specialoffers and select vision care. Members can take advantage of savings opportunities from dozens of vendors on a variety of products and services, including LASIK vision surgery, hearing services and aids, wellness products, weight loss programs, fitness memberships, elder care services, more. * and much 1 Please ask your provider for his/her recommendation as well as the progressive brands by tier. 2 Please ask your provider for his/her recommendation as well as the coating brands by tier. 3 A standard contact lens fitting includes spherical clear contact lenses for conventional wear and planned replacement. Examples include but are not limited to disposable and frequent replacement. 4 A premium contact lens fitting includes all lens designs, materials and specialty fittings other than standard contact lenses. Ex amples include but are not limited to toric and multifocal. OUT-OF-NETWORK If you choose an out-of-network provider, please complete an out-of-network claim form and submit it along with your itemized receipt to the fax number, address, or mailing address below. When visiting an out-of-network provider, discounts do not apply and you are responsible for payment of services and/or eyewear materials at the time of service. To Fax: To oonclaims@eyewearspecialoffers.com To Mail: Blue View Vision Attn: OON Claims P.O. Box 8504 Mason, OH Blue View Vision is for routine eye care only. If you need medical treatment for your eyes, visit a participating eye care physician from your medical network. If you have questions about your benefits or need help finding a provider, visit anthem.com or call us at This is a primary vision care benefit intended to cover only routine eye examinations and corrective eyewear. Benefits are payable only for expenses incurred while the group and insured person s coverage is in force. This information is intended to be a brief outline of coverage. All terms and conditions of coverage, including benefits and exclusions, are contained in the member s policy, which shall control in the event of a conflict with this overview. Discounts referenced are not covered benefits under this vision plan and therefore are not included in the member s policy. Frame discounts may not apply to some frames where the manufacturer has imposed a no discount policy on sales at retail and independent provider locations. Discounts are subject to change without notice. This benefit overview is only one piece of your entire enrollment package. Transitions and the swirl are registered trademarks of Transitions Optical, Inc. Photochromic performance is influenced by temperature, UV exposure and lens material. Anthem Blue Cross and Blue Shield is the trade name of: In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE Managed Care, Inc. (RIT), Healthy Alliance Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-hmo benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Ohio: Community Insurance Company. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWi), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation (Compcare), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are the registered marks of the Blue Cross and Blue Shield Association. 7/12

17 NON-COMMISSIONED BENEFIT COUNSELORS COMMUNICATION FOCUS Enrollment for: Medical Insurance Dental Insurance Vision Insurance Flexible Spending Accounts Critical Illness Insurance Accident Insurance Disability Insurance Universal Life Insurance Term Life Insurance Benefit Partners Anthem Ameriflex Lincoln Financial Group One America- AUL Trustmark The Strength of Steele Steele Benefit Services 9020 Crawfordsville Rd. Indianapolis, IN (317)

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