Vision Benefit Summary
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1 Vision Benefit Summary Scott County Board of Education Exam Every 12 months Plan Frequencies Lenses Every 12 months Frames Every 24 months Co-payments Exam $10 Lenses and/ or Frames $15 Maximum Allowances In Network Out of Network 1 (after co-payments up to plan limits) Eye Exam Paid in full $35 Single Paid in full $26 Bifocal Paid in full $40 Lenses (per pair) 2 Trifocal Paid in full $60 Lenticular Paid in full $100 Medically necessary 3 Paid in full $300 Contact Lenses 3 Elective (Fitting, follow up & lenses) $105 $105 $120 approximate retail Frame $40 wholesale $59 retail equivalent⁴ Lasik Members receive a 10% discount off UCR charges at preferred LASIK provider locations, and pay no more than $1,800 per eye for the Conventional LASIK procedure and $2,300 per eye for CustomLASIK. Members receive benefits where TLC Truvision network providers are available, with the following preferred rates: * Silver Package: $895/eye for Conventional LASIK * Gold Package: $1,295/eye for CustomLASIK * Platinum Package: $1,895/eye for CustomLASIK plus Bladeless LASIK (using Intralase technology). Calendar Year Deductible Calendar Year Maximum Benefit Lifetime Maximum Benefit Waiting Periods None, after plan Co-payments Up to plan limits Unlimited None 1 The amounts shown are maximum benefits. The actual benefit amount the plan will reimburse to a plan member for non-network doctors will be the least of the maximum shown in the schedule, the amount actually charged, or the amount a doctor usually charges a private patient. The availability of services under the non-network reimbursement schedule is subject to the same time limits and copayments as those for network services. The plan pays nonnetwork benefits in place of services from a network doctor. 2 Members receive additional fixed copayments on lens options including: anti-reflective coatings, polycarbonate, high index, progressive and transition lenses. 3 This allowance is paid with the same frequency as lenses, in place of the lens and frame benefit. 3 Medically necessary (prior authorization required) is defined as 1) following cataract surgery without intraocular lens, 2) correction of extreme visual acuity problems not correctable with glasses, 3) anisometropia greater than 5.00 diopters and asthenopia or diplopia, with spectacles, 4) Keratoconus, or 5) moncular aphakia and/or binocular aphakia where the doctor certifies contact lenses are medically necessary for safety and rehabilitation to a productive life. 4 The retail value may differ and are based on two to three times the wholesale cost. Actual savings may vary.
2 Subscriber Service Form Group Name: Scott County Board of Education Vision Group #VS3348 Subscriber Name: SS# - - A. CHANGES: Name: Address To: From: To: Telephone To: ( Add Dependent: City State Zip ) Name Birth Date / / Male Female Name Birth Date / / Male Female Name Birth Date / / Male Female Name Birth Date / / Male Female Delete Dependent: Effective Date of Change: / / (DATE MUST BE THE 1 ST OF THE TERMINATION MONTH) B. Terminate Policy (Reason) Date of Termination / / C. Reinstate Policy (Reason) Effective Date of Reinstatement / / D. Other(Explain) Signature Person initiating request (subscriber, administrator, etc.) Please fax to: ******Please be sure your Group # and Effective Date are on all forms before faxing!******
3 VS3348 PLEASE CHECK YOUR CHOICE Vision Care Plan Monthly Rates 01/01/ /31/2015 Employee Only $ 7.80 Employee + One $15.62 Employee + Family $22.94 Please fax to:
4 See the difference a bigger, better HumanaVision network can make for you. HumanaVision VCP has a newly expanded network. Choose from more than 35,000 participating optometrist, ophthalmologist, and national retail locations, including LensCrafters, Pearle Vision, Sears Optical, Target Optical, and JCPenney. HumanaVision offers: Cost-Savings Your benefits for eyewear apply at even more HumanaVision provider locations. And you ll pay the same cost for frames no matter where you go. Choice You now have access to exclusive lines of designer frames, such as Dolce & Gabbana, Oakley, Prada, Ralph Lauren, and Ray-Ban. Convenience Take care of eye exams and frames all in one visit. Many locations offer night and weekend appointments to fit your schedule. HumanaVisionCare.com
5 Finding a provider is easy. Call Customer Care at or go to HumanaVisionCare.com. To offer the widest choice, HumanaVision also includes independent optometrists and ophthalmologists located throughout the country. For a complete listing of providers near you, visit humanavisioncare.com. Looking for a great pair of glasses to fit your unique personality and lifestyle? LensCrafters is the right place for you. You can choose from a wide selection of fashion frames including the latest designers like Prada, Versace, Burberry, and Dolce & Gabbana. Add the latest lens technology for that great pair of glasses. More than 850 locations nationwide. Visit lenscrafters.com for the latest styles and trends and your nearest location. Pearle Vision continues the legacy of personalized eye care that Dr. Stanley Pearle started over 45 years ago. Combine that with a great selection of frames and lens options and over 750 convenient locations to make Pearle Vision a great place for your family s eye care. Go to pearlevision.com to learn more. Sears Optical has been helping families see better and look great at the right price for over 45 years. Everything you love and trust about Sears is what you ll find at Sears Optical professional service, stylish selection of frames and the latest contact lens advancements, quality, and great value for the entire family. Satisfaction guaranteed or your money back. More than 850 Sears Optical locations are conveniently located nationwide. Visit searsoptical.com for one near you. Your eyes. Your style. Target Optical provides fashion for less than you ve come to expect from Target, with the care of a professional independent doctor of optometry. You can choose from a huge selection of frames and sunglasses, including brands like Mossimo, Vogue, and Versus. The latest contact lens technology is also available at affordable prices. Visit target.com for more information. JCPenney Optical is a full-service optical center conveniently located in more than 350 JCPenney department stores. Choose from hundreds of frames that will inspire and reflect your lifestyle, including exclusive designer brands such as Bisou Bisou, a.n.a., Liz & Co., and Arizona. JCPenney Optical also offers eye exams, contact lenses, and non-prescription sunwear to meet all of your eyewear needs. Insured by Humana Insurance Company, CompBenefits Insurance Company, CompBenefits of HumanaDental Insurance Company, CompBenefits Company, or The Dental Concern, Inc. GCA0AV3HH 4/11
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