FlexAbility Vision Plan

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Damon Pope
5 years ago
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1 FlexAbility Vision Plan TABLE OF CONTENTS (Click on any item below to go to that section) Overview Claims Administrators Working with Vision Providers Preferred Providers Non-Preferred Providers What Is Covered Vision exam Corrective eyewear Prescription lenses Frames Contact lenses Subnormal vision aids What Is Not Covered If Your Claim Is Denied End of Coverage Overview FlexAbility offers a vision plan for members. If you or your dependents do not need vision coverage, you can select the Opt-Out option. The vision plan providers are part of a network, so if you use preferred providers the plan pays higher benefits. Some important reminders about the vision plan: You may have one vision exam per year, that is, one every 365 consecutive days. You may purchase contacts once during a 365-day period. You may purchase lenses for your glasses once during a 365-day period. You may purchase frames once during a 730-day period; however, you cannot purchase frames/lenses and contacts within the same 365-day period. Included in this section is a chart explaining your schedule of benefits, this is a quick guide to what is covered under your vision plan. This plan description isn't complete without a list of participating ophthalmologists, opticians, and optometrists in your area. For a complete list of providers, visit the online provider directory at

2 Claims Administrators If you have questions about your vision plan, you can call your Claims Administrator. Your Claims Administrator is: Northwest Benefit Network 2323 Eastlake Ave. E. Seattle, WA (800) (206) Preferred providers Working with Vision Providers Preferred providers Your vision plan has special contractual arrangements with selected vision providers to make sure you get high-quality care for a reasonable cost. When you go to preferred providers, you will receive the highest level of benefits this plan provides. (See the preferred provider column on the schedule of benefits.) You can find the list of participating providers online at You must bring a signed, completed NBN form with you at the time of service and give it to the provider. Claim forms may be obtained from your Human Resources office. Preferred providers submit your claim directly to your Claims Administrator. They may send you an informational statement after they have billed the Claims Administrator. Preferred providers will normally collect for items not covered by the plan when they are ordered. Non-preferred providers You may also go to non-preferred vision providers (any licensed vision provider not on the preferred provider list) for your vision plan care. When you go to non-preferred providers, you will pay more of the bill than if you were to go to preferred providers. (See the non-preferred provider column on the schedule of benefits below.) If you see a non-preferred provider, please send an itemized statement with a completed claim form directly to your Claims Administrator. Claim forms may be obtained from your Human Resources office. Claims submitted more than one year after the date of service will not be accepted.

3 What Is Covered Benefit Preferred Provider Non-preferred provider Vision exam (one every 365 days) 100% $35 Basic lens (one pair every 365 days) Single-vision 100% 1 $30 per pair Bifocal 100% 1 $40 per pair Trifocal 100% 1 $45 per pair Contacts (includes exam, fitting and lenses) Up to $300 2 $90 per pair Subnormal Vision Aids (covered only for limited conditions) Up to $350 1 $90 per pair Lens "extras" Scratch coat Covered Additional 1 Oversize Covered Additional 1 Photochromatic Covered for glass only Additional 1 Prism segs Covered Additional 1 Tints #1 and #2 Covered Additional 1 Blended/progressives Additional 1 Additional 1 High index Additional 1 Additional 1 Sunglass tints and coating Additional 1 Additional 1 Other extras Not covered Not covered If you see a Washington or Alaska provider: Frames (once every 730 days) Up to $85 wholesale 1 $30 retail If you see an Oregon provider: Frames (once every 730 days) Up to $200 retail 1 Covered $30 retail Additional 1 1 Member pays any dispensing fees and any additional cost over basic lenses and for frames which cost more than the plan allowance. 2 Contact benefit includes exam, fitting, and lenses up to $300 total. Member has up to six months from the date of the exam to purchase contacts. Future eligibility will be based upon the date of the exam. Vision exam The exam may consist of external and ophthalmoscopic examination, determination of the best corrected visual acuity, determination of the refractive state, gross visual fields, basic sensorimotor examination, and glaucoma screening.

4 Corrective eyewear When your vision exam results in an eyewear prescription, your vision benefit covers corrective eyewear. Covered eyewear includes benefits for new prescription lenses, frames, or contact lenses up to the plan limits. If NBN is billed for an exam and at a later date receives a bill for lenses and/or frames, they will track eligibility for each service/material from service date to service date. Prescription lenses New prescription lenses are available based on the benefit schedule. Allowable materials used to make the lenses include white crown glass hardened and drop-ball tested, or white plastic lenses (including anti-scratch coating or treatment) with a #1 or #2 tint, ground or molded to be fitted into frames. Lenses covered are monofocal, bifocal, trifocal, and mono-and multi-aphakia. You pay any additional cost over the basic lens cost for blended/progressive lenses, and other cosmetic extras. Frames New frames may be obtained based on the benefit schedule. If you select frames that cost more than the plan allowance, you will be responsible for any additional cost over the plan maximum. Contact lenses If you choose to obtain contact lenses, the plan will make an allowance based on the benefit schedule toward the cost of the exam, lenses and fitting in lieu of all other benefits for the year. If you choose disposable contact lenses, you may obtain a supply up to the maximum allowance. Please note - you must be eligible for an exam and lenses in order to receive contact lenses. Subnormal Vision Aids Contact lenses prescribed as a subnormal vision aid are covered under the Plan for the following conditions: 1. After cataract surgery. (If necessary, NBN will provide lenses and frames in addition to contact lenses after cataract surgery. However, prior approval must be obtained. A member would again be eligible for an annual examination and lenses after 365 days, frames after 730 days, and contact lens replacement after 365 days, if a change in prescription is indicated) 2. Keratoconus (bulging cornea) 3. When vision acuity is not correctable to 20/70 in the better eye by use of conventional type lenses, but can be improved by 20/70 or better by the use of contact lenses What Is Not Covered The following items are not covered under the vision plan: Aniseikonic lenses Coated or tinted lenses other than anti-scratch coating or treatment Replacement of lost or broken lenses Subnormal vision aids obtained without prior approval Medical ophthalmological services and/or treatment other than those stated above

5 Orthoptics or vision training Sunglasses and lenses tinted #3 or above, or plastic photochromatic lenses Thinlite or flint or high index lenses Two pairs of glasses or two pairs of contacts, or one pair of glasses and one pair of contacts Frames cost exceeding the amount covered by the plan Any materials not mentioned as covered above Surgery to correct refractive errors Experimental or investigative treatments and vision practices not accepted in the service area as determined by your Claims Administrator Services and supplies with no charge, or that the employer would have paid if properly applied for Any work-related injury or illness Services or materials provided when not a member in this plan Non prescription glasses or contacts If Your Claim Is Denied Your vision plan has a three-stage formal grievance process for members. If you think we should take action on a complaint about any of our services or procedures, please tell your Claims Administrator about the issue or incident. Before filing a formal grievance, talk to a Claims Administrator Customer Service Representative. We'll try to resolve your problem informally. Step I: Formal complaint If you're not satisfied, within 60 days of the incident, send a written complaint to your Claims Administrator. This should include a description of the problem, the date it occurred, and the full names of providers or others involved. Please include your full name, group name and social security number. The Claims Administrator will respond in writing within 45 days of receiving your letter. Step II: Grievance hearing If you are dissatisfied with the response to your complaint, you have 30 days to file a written request for a hearing before the Grievance Review Committee. You will have a chance to present your position before the committee. The committee will send a written decision to you within 30 business days of the hearing. Step III: Appeals If you are still dissatisfied with the decision, you have 30 days to submit a written appeal to PeaceHealth. Send your appeal to:

6 FlexAbility Plan Administrator PeaceHealth SE Eastgate Way, Suite 300 Bellevue, WA You will receive a response to your appeal from the Plan Administrator by mail within 90 days after the Plan Administrator receives the appeal. If the Plan Administrator needs more than 90 days to review your appeal, you will be notified of the delay and the reasons for it. End of Coverage Your coverage terminates at the end of the month in which you cease to be an eligible employee. Coverage of dependents terminates at the end of the month in which your coverage terminates, or the dependent ceases to be an eligible dependent, whichever occurs first. (See Health Benefit Protection in the "What You Need to Know" section.) Coverage may also be terminated for you and/or your dependents for these reasons: You give false or misleading information on your application or other forms. You let someone else use your membership card or you use your benefits fraudulently in other ways. You do not comply with the terms of your agreement with the vision plan, as described in this handbook. Coverage may be retroactively terminated as of the day the rules are broken, even if the Claims Administrator discovers it much later. You are responsible for any charges made after coverage is terminated. Coverage will not be terminated on any individual member for health or medical reasons.

VISION PLAN PROVISIONS

VISION PLAN PROVISIONS Schedule of Vision Plan Benefits NBN Network Provider Examination Paid in full $ 35 Lenses (per pair) Single Vision Paid in full* $ 30 Bifocal Paid in full* $ 40 Trifocal Paid in