Vision Insurance - Gold. Enrollment brochure Freedom to choose any vision care provider

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Gertrude Fisher
5 years ago
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1 Enrollment brochure Vision Insurance - Gold Freedom to choose any vision care provider Network option for even greater savings Annual eye exam and single or bifocal lenses at no cost from participating network providers No deductibles

2 Highlights Offering Vision benefits does a lot more than provide employees with access to discounted eye wear. Regular eye exams can provide early detection of eye diseases, as well as health conditions like diabetes and high blood pressure. Highlights of our plans include: Members can choose any vision care provider but may pay less for services from network providers. All members receive an annual eye exam and single or bifocal lenses at no cost from participating network providers. No deductibles. The Network Advantage Participating Providers You have the freedom to visit the Vision Care provider of your choice, but out-of-pocket expenses may be reduced significantly when choosing a network provider. Our network has more than 40,000+ eye care professionals including retailers and independent doctors nationwide. Participating providers accept discounted fees for their services. So, when visiting a network provider, out-of-pocket expenses may be reduced significantly. Locate participating providers at: Using the Network is easy No ID cards are required! In-network providers can easily verify member information and eligibility for services without an ID card, however for easy identification and reference, members may print them from their member portal. No claim forms are needed for services from a participating network provider! Simply inform the providers office with the covered member s ID number and/or name and date of birth.

3 Exam Once every 12 months 1 Up to $70 Gold Plan Features In-network benefits Out-of-network reimbursements Lenses Once every 12 months 1 Lens Options Single vision Up to $45 Bifocal vision Up to $115 Intermediate vision Up to $115 Trifocal Up to $190 Lenticular Up to $190 Once every 12 months 1 Scratch resistant coating Fashion/gradient tint Solid tint Glass photogrey single vision lens Glass photogrey bifocal and trifocal lens Ultraviolet (UV) coating Standard anti-reflective (AR) coating after $35 copay Polarized lenses Discounted to $75 2 Polycarbonate lenses Standard progressive lenses Premium progressive lenses after $40 copay Frames Once every 12 months 1 Frame allowance $175 retail allowance 5 (20% overage discount) Contacts Once every 12 months 1 (In lieu of eyeglasses) Maximum allowance for conventional lenses Maximum allowance for disposable lenses $175 retail allowance (15% overage discount 3 ) $175 retail allowance (10% overage discount 3 ) Medically necessary contact lenses 4 Evaluation, fitting, and follow-up care - standard lens Evaluation, fitting, and follow-up care - specialty lens after $20 copay (daily wear lenses) 6 after $30 copay (ext. wear lenses) 6 after $50 copay 6 N/A Up to $100 Up to $290 N/A 1 Benefit year is based on member s last date of service. 2 Actual discounted amounts may vary. 3 Does not apply at Contact Fill or Cole corporate locations (if applicable) and where prohibited by law. Prohibited by some manufacturers. 4 Prior authorization required. 5 Does not apply for certain proprietary frame brands and where prohibited by law. 6 Only covered if member chooses contact lenses.

4 Additional Advantages from NVA EYEESSENTIAL Plan After you have exhausted your funded benefit, you re eligible to access significant discounts on materials through participating network providers. NVA Smart Buyer The NVA Smart Buyer program provides you with the tools you need to become an educated consumer of vision care services and eye wear. It s the only source that integrates your vision benefit coverage with the unbiased information you ll need to maximize your vision benefit and reduce your out-of-pocket expense. Vision Benefit Maximizer Eyecare Professional Search Tool Find an eyecare professional and view their service level (i.e. full service, exam only, etc.) and frame inventory (i.e. number of frames they have available including numbers of frames available at no out-of-pocket cost to you with your vision benefit, this service is exclusive to NVA s Vision Benefit Maximizer). NVA Smart Buyer s Guide to Frames A detailed guide to the best approach for picking out eyeglass frames according to face shape, skin tone, eye and hair color, measurements, materials, and much more. NVA Smart Buyer s Guide to Eyeglass Lenses Use this guide to familiarize yourself with various eyeglass lens types, materials, lens coatings or treatments, enhancements, lens care and more. Convenient home delivery of replacement contact lenses through Contact Fill Laser Eye Surgery - The National LASIK Network Members are entitled to significant discounts and a free initial consultation with all in-network providers. Online Member Tools Once enrolled, all members receive access to register for their own online account at Tools of the online member portal include: View eligibility information and print copies of ID cards Search participating eyecare professionals in the area or nominate a preferred eyecare professional (if not participating) Submit, view, and check the status of claims Find answers to our most frequently asked questions Use the online tools previously described above in Additional Advantages from NVA How it works Out-of-Network You have the freedom to choose any vision care provider. When choosing an out-of-network provider, you ll pay the fees for services and materials first to the provider at point of service and are then reimbursed according to your plan s schedule. Out-of-network claims: For services from an out-of-network provider, you may need to submit a claim form for reimbursement.

5 Exclusions and Limitations This is a partial listing of benefits only. Please refer to the policy for details. No benefits are payable except as stated in the policy. This insurance does not apply to any expense for: 1. Cosmetic services or supplies; 2. Services rendered by a member of the treated person s immediate household or family; 3. Treatment by someone not a licensed Optician, Optometrist, Ophthalmologist or a licensed medical practitioner; 4. Eye examinations for which benefits are paid or will be paid under any health care program supported in whole or in part by funds of the federal government or any state or political subdivision; 5. More than one Vision Analysis, Vision Survey or refraction in any one Benefit Year; 6. Eye glasses or frames for which the Insured is reimbursed under any group hospitalization or medical expense reimbursement plan, to the extent of such payment or reimbursement; 7. More than one pair of lenses or frames per person in any one Benefit Year; 8. Contact lenses provided for cosmetic purposes only; 9. Contact lens fitting examinations; 10. Non-prescription lenses, glasses or goggles; 11. Services performed as a result of any injury or illness covered by workers compensation; 12. Any service or treatment for which payment is not legally required; 13. Charges for broken or missed appointments; 14. Time spent completing insurance forms; 15. Treatment for intentionally self-inflicted injury; 16. Services or supplies that are not recommended by a Vision Provider; 17. Treatment for disease, defect, injury or loss caused by war or act of war, declared or not; or by a war-like act in time of peace; 18. Charges incurred as a result of illness or disease or accidental bodily injury; 19. In network co-payments whether incurred on this or any other vision benefit plan. The information in this material is not intended as an offer of coverage. It is for illustrative purposes only, providing a general overview of featured benefit highlights provided under the policy. It is not a contract. The information in this material is not intended as an offer of coverage. It is for illustrative purposes only, providing a general overview of featured benefit highlights provided under the policy. It is not a contract. In the event of conflicting information with the policy, the policy will take precedence over what is shown in this material. The policy described in this material covers Vision benefits only. Not available in all jurisdictions. Policies are subject to Underwriting approval. All coverage extends up to policy limits. Policies are reviewed annually and may be cancelled for nonpayment. Please refer to the policy for coverage details, a complete listing of covered services, policy provisions, conditions, exclusions, and terms under which the policy may be continued or cancelled. ShelterPoint is a registered Service Mark. All images licensed through istockphoto. Not available in all jurisdictions. Underwritten by: ShelterPoint Insurance Company (licensed in 48 jurisdictions, not including NY) in: NJ (SPI GV0215 P NJ), PA (SPI GV0215 P PA) M#15-139a V - b5 gold - EE - NJ/PA - G1a 04/15a sales@shelterpoint.com ( ) sheltering you facebook.com/shelterpointgroup

If you use an IN-NETWORK provider (Member cost) $10 Up to $39. Up to $55 10% off retail. $150 allowance 20% off balance over $150

If you use an IN-NETWORK provider (Member cost) $10 Up to $39. Up to $55 10% off retail. $150 allowance 20% off balance over $150 SGB0168A Humana Vision 130 FLORIDA Vision care services Exam with dilation as necessary Retinal imaging 1 Contact lens exam options2 Standard contact lens fit and follow-up Premium contact lens fit and