BlueCross Vision SM Vision Plan 1
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1 BlueCross Vision SM Vision Plan 1 H I G H L I G H T S Benefit frequencies are based on date of service VISION EXAMINATION FRAMES 1 Participating P L A N A L L O W A N C E S Non-participating 100% after $10 copay $32 $120 $60 plus 30% off the retail balance 2 EYEGLASS LENSES (per pair) 1 & 3 Single Vision Standard Lenses 100% after $10 copay $24 Bifocal Standard Lenses 100% after $10 copay $36 Trifocal Standard Lenses 100% after $10 copay $46 Aphakic/Lenticular Standard Lenses 100% after $10 copay $72 CONTACT LENSES 1 & 3 Disposable (unlimited boxes) $100, plus 25% off the retail balance 2 & 4 $75 Conventional including, but not limited to: Hard/soft daily wear and spherical $100, plus 25% off the retail balance 2 & 4 $75 Specialty lenses including but not limited to: Bifocal, toric or gas permeable $100, plus 25% off the retail balance 2 & 4 $75 Medically necessary (per pair) 100% $75 CONTACT LENS FITTING & FOLLOW UP Daily wear 100% $20 Extended wear 100% $30 Specialty $50 copay Not covered Programs are subject to change. This is not a contract. This information highlights vision benefits and is not intended to be a complete list or complete description of available services. Contact your employer, marketing representative, or broker for additional benefit details. 1 Walmart/Sam s Club: To maintain comparable values with Walmart s pricing structure, your frame allowance will be 50% of the allowance shown above with no additional retail discounts. Your contact lens allowance will be 75% of the allowance shown above with no additional retail discount. Walmart/Sam s Club stores accept BlueCross Vision for materials, not Lens Options. Doctors affiliated with Walmart/Sam s Club are not Walmart employees; therefore, participation for exams varies. 2 Discounted amounts may vary and may not be honored at all optical retailers. 3 Payment will be made for either lenses or contact lenses within a benefit period. Payment will not be made for both. 4 Retail discounts do not apply to Contact Fill. VALUE ADDED DISCOUNTS 4 LENS OPTIONS Member cost Solid Tint $10 Fashion / Gradient Tint $12 Standard Scratch-Resistant Coating $10 Ultraviolet Coating $12 Standard Anti-reflective Coating $40 Glass Photogrey $20 (SV); $30 (bifocal/trifocal) Polarized $75 Standard Progressive Lenses 5 $50 Premium Progressive Lenses 5 $100 Transitions Polycarbonate Standard Lenses $65 (SV);$70 (bifocal/trifocal) $25 (SV); $30 (bifocal/trifocal) Blended Bifocal (Segment) $30 High Index $55 Additional supplies (excluding contact lenses) LASIK SURGERY 20% off retail Retail Discount Benefits are issued by Capital Advantage Assurance Company, a subsidiary of Capital BlueCross. Independent licensees of the BlueCross BlueShield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies.
2 Value Added Plus 4 Value Added Plus provides discounts on additional purchases during the benefit period after the funded benefits have been exhausted. Benefit frequencies are unlimited SERVICE AND MATERIALS VISION EXAMINATION FRAMES EYEGLASS LENSES (per pair) Member cost Balance after $10 Discount 35% off retail Single Vision Standard Lenses $35 Bifocal Standard Lenses $55 Trifocal Standard Lenses $70 Aphakic/Lenticular Standard Lenses $70 CONTACT LENSES Disposable (unlimited boxes) Conventional including, but not limited to: Hard/soft daily wear and spherical Fitting & Follow up 10% off retail 15% off retail 10% off retail LENS OPTIONS Ultraviolet Coating $12 Tint (Solid & Gradient) $12 Scratch-Resistant Coating (Standard) $15 Polycarbonate (Standard) $35 Anti-Reflective Coating (Standard) $45 Polarized $75 Transitions (Standard) Standard Progressive Lenses Additional supplies $65 (Single vision) $70 (bifocal or trifocal) $50+ Bifocal or trifocal lens charge 20% off retail Programs are subject to change. This is not a contract. This information highlights vision benefits when you visit a participating provider and is not intended to be a complete list or complete description of available services. Contact your employer, marketing representative, or broker for additional benefit details. 4 Value Added Discounts & Value Added Plus are not part of the insured benefits. Value Added Discounts & Value Added Plus are a reduced fee-for-service discount program. Members pay a discounted amount for listed services by participating providers. Capital BlueCross does not pay the participating providers for these services. Discounted pricing does not apply at Walmart, Sam s Club and select retailers. Discounted amounts may vary and may not be honored at all participating provider locations. Contact your provider s office to verify their participation in this program. 5 Fixed discounted pricing is not available on all brands 6 Retail discounts do not apply to Contact Fill. Deductibles, coinsurance and copayments under this program are separate from any deductibles, coinsurance and copayments described in your company s other health benefits coverage. Value Value Plan Plan Individual - Individual CBC-3515 CBC-3515 V V (1/1/2017) (1/1/2017)
3 Capital BlueCross and its family of companies comply with applicable federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability, or sex. If you, or someone you're helping, has questions about your health plan, you have the right to get help and information in your language at no cost. To talk to an interpreter, call (TTY: 711). Spanish Si usted, o alguien a quien usted está ayudando, tiene preguntas acerca de su plan de salud, tiene derecho a obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete, llame al (TTY: 711). Chinese 如果您, 或是您正在協助的對象, 有關於您的健康计划方面的問題, 您有權利免費以您的母語得到幫助和訊息 洽詢一位翻譯員, 請撥電話 [ 在此插入數字 (TTY: 711) Value Plan 1 - Individual CBC-3515 V (1/1/2017)
4 This Page Left Intentionally Blank. Extra line Value Plan 1 - Individual CBC-3515 V (1/1/2017)
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ENROLLMENT REQUEST FORM
ENROLLMENT REQUEST FORM Please contact Affinity Health Plan if you need information in another language or format (braille. To Enroll in Affinity Health Plan, Please Provide the Following Information:
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