El Pollo Loco Restaurants Eye Care Highlight Sheet

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Gervais Franklin
6 years ago
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1 Plan 1: Basic Vision Plan Summary Effective Date: 11/1/2017 $0* Maximum Calendar Year None Annual Eye Exam Up to $45 Single Vision Up to $35 Bifocal Up to $50 Trifocal Up to $65 Lenticular Up to $70 Progressive Up to $70 Elective/Medically Necessary Up to $115 Frames $80 Exam/Lens/Frame 12/12/24 *** *Deductible applies to the first service received ***Please submit claims within 90 days of the date of service so that the plan can consider benefits (subject to State requirements). Eyewear Savings Plan members may receive up to 15% off eyewear frames and lenses purchased at any Walmart Vision Center nationwide. Members may also bring in their current vision prescription from any vision care provider and purchase eyewear at Walmart. This savings arrangement is not insurance: it is available to members at no additional cost to their plan premium. To receive the eyewear savings identification card, plan members can visit reliancestandard.com/dental-vision and sign-in (or create) a secure member account. Members must present the Eyewear Savings Card at time of purchase to receive the discount. California state law requires that coverage shall be provided to Registered s that is equal to, and subject pm (CST) on Fridays. You can call toll-free at Your claim forms can be faxed in to (402) We will be happy to answer any questions you may have regarding a specific claim you have filed or to answer questions about benefits for eye care procedures being considered. This form is a benefit highlight, not a certificate of insurance. The coverage outlined here highlights the benefits available through Reliance Standard Life, and does not include exclusions and limitations. For details on exclusions and limitations, or a complete list of covered procedures, contact your benefits coordinator.

2 Plan 2: TrueView Plan H Summary Effective Date: 11/1/2017 EyeMed Select Network $10 Exam No deductible $25 Eye Glass Lenses Annual Eye Exam Covered in full Up to $30 Single Vision Covered in full Up to $25 Bifocal Covered in full Up to $40 Trifocal Covered in full Up to $55 Lenticular 20% discount Progressive See lens options NA Fit & Follow Up Exams Standard Standard: Member cost up to $40 Premium (Allowance) Premium: 10% off of retail Elective Up to $115 Up to $100 Medically Necessary Covered in full Up to $200 Frames $100 Up to $45 Exam/Lens/Frame 12/12/24 12/12/24 Lens Options (member cost) Progressive Lenses Standard Premium EyeMed Select Network Standard: $65 + lens deductible Premium: lens cost - 20% discount - $120 allowance + Standard Progressive cost Std. Polycarbonate $40 Tint (solid and gradient) $15 Scratch Resistant Coating $15 Anti-Reflective Coating $45 Ultraviolet Coating $15 Lasik or PRK Average discount of 15% off retail price or 5% off promotional price at US Laser Network participating providers.

3 Additional TrueView H Features EyeMed In-Network Discounts EyeMed In-Network Secondary Purchase Plan Contact Lens Replacement by Mail Program 15% discount off the remaining balance in excess of the conventional contact lens allowance. 20% discount off the remaining balance in excess of the frame allowance. 20% discount on items not covered by the plan at network providers, which may not be combined with any other discounts or promotional offers. This discount does not apply to EyeMed Provider's professional services, or contact lenses. Members receive a 40% discount on a complete pair of glasses once the funded benefit has been exhausted. Members receive a 15% discount off the retail price on conventional contact lenses once the funded benefit has been exhausted. Discount applies to materials only. After exhausting the contact lens benefit, replacement lenses may be obtained at significant discounts on-line. Visit EyeMedvisioncare.com for details. California state law requires that coverage shall be provided to Registered s that is equal to, and subject pm (CST) on Fridays. You can call toll-free at Your claim forms can be faxed in to We will be happy to answer any questions you may have regarding a specific claim you have filed or to answer questions about benefits for eye care procedures being considered. This form is a benefit highlight, not a certificate of insurance. The coverage outlined here highlights the benefits available through Reliance Standard Life, and does not include exclusions and limitations. For details on exclusions and limitations, or a complete list of covered procedures, contact your benefits coordinator.

4 Plan 3: Sharper Vision Plan Summary Effective Date: 11/1/2017 VSP Choice Network + Affiliates $10 Exam $10 Exam $25 Eye Glass Lenses or Frames* $25 Eye Glass Lenses or Frames Annual Eye Exam Covered in full Up to $45 Single Vision Covered in full Up to $30 Bifocal Covered in full Up to $50 Trifocal Covered in full Up to $65 Lenticular Covered in full Up to $100 Progressive See lens options NA Fit & Follow Up Exams Member cost up to $60 Elective Up to $130 Up to $105 Medically Necessary Covered in full Up to $210 Frames $130** Up to $70 Exam/Lens/Frame 12/12/24 12/12/24 *Deductible applies to a complete pair of glasses or to frames, whichever is selected. **The Costco allowance will be the wholesale equivalent. Lens Options (member cost)* VSP Choice Network + Affiliates (Other than Costco) Progressive Lenses Up to provider s contracted fee for Lined Up to Lined Bifocal allowance. Bifocal Lenses. The patient is responsible for the difference between the base lens and the Progressive Lens charge. Std. Polycarbonate Covered in full for dependent children $33 adults Solid Plastic Dye $15 (except Pink I & II) Plastic Gradient Dye $17 Photochromatic Lenses $31-$82 (Glass & Plastic) Scratch Resistant Coating $17-$33 Anti-Reflective Coating $43-$85 Ultraviolet Coating $16 *Lens Option member costs vary by prescription, option chosen and retail locations.

5 Additional Sharper Vision Choice Network Features Contact Lenses Elective Allowance can be applied to disposables, but the dollar amount must be used all at once (provider will order 3 or 6 month supply). Applies when contacts are chosen in lieu of glasses. For plans without a separate contact lens fit & follow up exam allowance, the cost of the fitting and evaluation is deducted from the contact allowance. Additional Glasses Frame Discount Laser VisionCare Low Vision 20% discount off the retail price on additional pairs of prescription glasses (complete pair). VSP offers a 20% discount off the remaining balance in excess of the frame allowance. VSP offers an average discount of 15% on LASIK and PRK. The maximum outof-pocket per eye for members is $1,800 for LASIK and $2,300 for custom LASIK using Wavefront technology, and $1,500 for PRK. In order to receive the benefit, a VSP provider must coordinate the procedure. With prior authorization, 75% of approved amount (up to $1,000 is covered every two years). Retail Chain Affiliate Providers Available With Sharper Vision Effective January 1, 2012, retail chain affiliate providers, which include Costco Optical and Visionworks, give members added convenience and additional retail choices. Costco Optical has 400 locations across the country, while Visionworks manages nearly 400 optical stores in 37 states and DC, including well-known stores such as EyeMasters, Visionworks, Dr. Bizer s VisionWorld, Eye DRx, and Hour Eyes, to name a few. Members enjoy a covered-in-full benefit experience with equivalent frame benefit at any of these retail chain locations. VSP Information For more information regarding the VSP provider network or to find out more about VSP, please visit the VSP web-site at California state law requires that coverage shall be provided to Registered s that is equal to, and subject pm (CST) on Fridays. You can call toll-free at Your claim forms can be faxed in to (402) We will be happy to answer any questions you may have regarding a specific claim you have filed or to answer questions about benefits for eye care procedures being considered. This form is a benefit highlight, not a certificate of insurance. The coverage outlined here highlights the benefits available through Reliance Standard Life, and does not include exclusions and limitations. For details on exclusions and limitations, or a complete list of covered procedures, contact your benefits coordinator.

Oregon Association of Realtors Eye Care Highlight Sheet

Oregon Association of Realtors Eye Care Highlight Sheet Plan 1: Focus Plan Summary Effective Date: 1/1/2019 VSP Choice Network + Affiliates Deductibles $10 Exam $10 Exam $25 Eye Glass Lenses or Frames* $25 Eye Glass Lenses or Frames Annual Eye Exam Covered