CompBenefits Family of Companies
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1 About CompBenefits C ompbenefits, the dental and vision plan of choice for more than 5 million members nationwide, offers a portfolio of affordable products built on 25 years of service and stability. Since 1978, CompBenefits has maintained its commitment to meeting others needs with local focus, exceptional customer support and an unparalleled network of providers. Throughout its history, CompBenefits has grown to meet customer and provider expectations and remains committed to its leadership role in the dental and vision benefits industry. CompBenefits Family of Companies CompBenefits CompBenefits Company CompBenefits Insurance Company CompBenefits Dental, Inc. CompBenefits of Alabama, Inc. American Dental Plan of North Carolina, Inc. American Dental Providers of Arkansas, Inc. National Dental Plans, Inc. American Dental Plan of Georgia, Inc. Texas Dental Plans, Inc. Ultimate Optical, Inc. Primary Plus CBOV
2 COUNTY OF DUPAGE Open your eyes to high-quality vision care! The average family spends close to $600 each year on routine eye health care. Using CompBenefits, you will receive your routine eye health care with just a small copayment. CompBenefits provides benefits for covered: Eye health examinations Frames Eyeglass Lenses Contact Lenses Plus you will receive: LASIK surgery discount Preferred member pricing for other frame and lens options* When ordering from one of our network eye doctors, you will also receive in the year of your eye exam: A 20% discount on a second pair of eyeglasses A 15% discount on your contact lens fitting fee MONTHLY RATES SERVICE FREQUENCY COPAYMENTS Employee only: $ 5.74 Vision exam: Once every 12 months Exam: $10 Employee + family: $13.70 Lenses: Once every 12 months Materials: $15 Frame: Once every 24 months SAVINGS! SEE THE DIFFERENCE You can save money two ways with VisionCare. First, the cost of plan services and materials is discounted and prepaid. So except for any co-payments, you have no out-of-pocket expenses for covered services and supplies when you use one of our network doctors. Second, your coverage costs are deducted from your pay before any federal income or FICA taxes are taken out. This makes your taxable wage base lower, so you would pay less tax. Here s an example of how the plan helps you save over the course of a year: If You Get: You Pay: VisionCare Typical Doctor Retail Eye exam.00 $ Frame (designer style) Lenses: Single Vision Co-payments: $10 exam/$15 materials $ Premium ($5.74 monthly x 12) $ $ Pre-tax savings (assuming 18% tax bracket & 7.65% FICA) Total Cost $ $ YOUR TOTAL SAVINGS THROUGH VISIONCARE: 68% OFF RETAIL In this example, you would have saved $ in vision care costs with. Keep in mind, however, that your actual savings will depend on your plan allowances, your actual premium, the doctors and materials you select, and your own tax situation. * This is not a schedule of maximum benefits. For example, the plan covers frames based on the manufacturer s wholesale price guide. So while the retail price of a covered frame may vary among plan doctors, the value of your covered frame stays the same. Typically, the wholesale frame allowance is equivalent to a retail price of $ You may be required to pay extra only if you choose a frame that exceeds the covered wholesale price.
3 Maximum Allowances Eye Exam Paid in full Lenses (per pair) Single Paid in full Bifocal Paid in full Trifocal Paid in full Lenticular Contact Lenses Paid in full Elective (fitting, follow-up & lenses) $105** Medically necessary* Paid in full Frame $40 wholesale Lasik*** Participating Doctor (After copayments/ Up to plan limits) We have contracted with many of the finest LASIK facilities and eye doctors to offer this procedure at substantially reduced fees. The network of LASIK centers features all TLC Laser Center (TLC Vision) facilities as well as many of the leading independent centers in the country. * Medically necessary (prior authorization required) is defined as 1) following cataract surgery w/o 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) monocular aphakia and/or binocular aphakia where the doctor certifies contact lenses are medically necessary for safety and rehabilitation to a productive life. ** If you prefer contact lenses, the plan provides an allowance for your contacts instead of lenses and frames. *** Plan members must first contact CompBenefits for a list of providers and to receive a Refractive Care ID card. This schedule shows only a few of the covered procedures. Please see your Benefit Administrator for a complete schedule. This schedule is intended for comparison purposes only. The benefits of each plan will be determined by the contract. For a complete listing of benefits and exclusions and limitations, please reference your certificate of coverage. Out-of-network benefits apply under the VisionCare Plan, but benefits are higher when a participating doctor is utilized. Limitations and Exclusions apply. Discount Only HOW DOES VISIONCARE PLAN WORK? Your plan brochure tells you about your benefits, and you can choose a network provider at custom/countyofdupage. Depending on your plan, either you or your doctor will download a VisionPass Form from our website. You must use the form in the time specified for services*. Visit your doctor, who will provide you with a comprehensive eye exam and order prescribed eyeglasses or contacts, if necessary. Pay any copayments as well as any additional expenses for cosmetic items you have chosen. That s the end of your paperwork. CompBenefits pays the doctor directly for his or her professional services. It s as easy as that! * If you do not use your form in the time specified for services, you won t be able to download another until the next time you are eligible for benefits. However, you can request an extension from our Member Services team at CAN I GET CONTACTS INSTEAD OF LENSES? Yes. If you prefer contacts instead of glasses, your vision exam is covered-in-full with your exam co-payment and provides a generous allowance of $ to be applied towards your fitting and follow-up fees as well as materials costs. The Contact Lens allowance is in LIEU OF THE LENS / FRAME BENEFIT and is provided with the same frequency as your lens benefit. HOW DO I GET FURTHER QUESTIONS ANSWERED? You may contact CompBenefits Member Services Department with any questions or concerns at: , Monday Thursday 8am-8pm; and Friday 8am-6pm EST. or locate us on the web at: custom/countyofdupage.
4 VISION PROVIDERS DUPAGE COUNTY The providers listed in this brochure were participating with the plan at the time of printing. Please check with the doctor of your choice or call our Member Services department at when making your appointment to make certain he or she is currently a member doctor. You may also visit our website at for a nationwide listing of providers. You must receive services from one of our participating providers in order to receive full benefits (as outlined in your vision care booklet). If you receive service from a provider who does not participate in the plan, you will receive reimbursement according to the non-panel reimbursement schedule established by your group. DUPAGE Addison Schwartz, OD, Lenard 1250 W Lake St (312) Bensenville Riley, OD, Melanie A. 117 W Main St (630) Skowron, OD, Mark L. 117 W Main St (630) Bloomingdale Epstein, OD, Peter J 152 S Bloomingdale Rd Ste (630) Carol Stream Magee, OD, Lawrence M. 926 W Army Trail Rd (630) Darien Havrilla, OD, Ernest G S Cass Ave (630) Mueller, OD, Peter F Lemont Rd Ste (630) Richardson, OD, Robert R S Cass Ave (630) Downers Grove Afryl, OD, Glenn E Chiaramonti, OD, Nicholas A. Dygola, OD, Shawn A Hardesty, OD, Leonard B. Jairam, OD, Srinivas th St (630) Robert, OD, Todd A. Weil, OD, Linda S. Elmhurst Carr, OD, Thomas J Greenfield, OD, Jeffrey S. 210 N York Rd (630) Riley, OD, Melanie A. Skowron, OD, Mark L. Glen Ellyn Foreman, OD, Paul A. 534 Crescent Blvd (630) Meyers, OD, Cheryl S. Meyers, OD, Jeffrey D. Sikorski, OD, Martin J. Stack, OD, Catherine M. 534 Crescent Blvd (630) Roosevelt Rd (630) Glendale Heights Blinstrup, OD, Michael J Bloomingdale Rd (630) Nuccio, OD, Richard 2172 Bloomingdale Rd (630) Tran, OD, Christianna A Bloomingdale Rd Ste B (630) Hinsdale Armstrong-Lieberman, OD, Natal Grenier, OD, Paul J. Krone, OD, Robert L. Lieberman, OD, Daniel A. Miller, OD, Christopher T. Pham, OD, Camthu M. Roitstein, OD, Carrie B. Lisle Yu, OD, Josephine 3060 Ogden Ave (630) Lombard Brand, OD, William B 320 W Roosevelt Rd (630) Naperville Adlfinger, OD, Deann L Bechtold, OD, James R Chiaramonti, OD, Nicholas A. Dryier, OD, Lisa A Judycki, OD, Richard C Kesler, OD, Stacey L Khakoo-Khan, OD, Zeinur N. Kukla, OD, Kevin L. Marzec, OD, Anna McArdle, OD, George J 1852 Bay Scott Cir Ste (630) Owens, OD, Kristopher M Sesso, OD, Patrick B. Spevacek, OD, Lisa B Steinmetz, OD, Stephen P E Ogden Ave (630) Warnick, OD, Paul E Willenbring, OD, Michelle R. Wu, OD, Sandra Betty Oak Brook Franceschini, OD, Joseph A. 120 Oakbrook Ctr Ste (630) Roselle Langner, OD, Kristen A 46 E Irving Park Rd (630) Villa Park Butzon, OD, Steve P 619 W North Ave (630) Masterson, OD, Gary J. 270 W North Ave (630) Romm, OD, Victor 351 W North Ave (630) Westmont Judycki, OD, Richard C. 409 W Ogden Ave (630) Wheaton Brace, OD, Arthur W 115 Danada Sq E (630) Burch, OD, Christian G. 115 Danada Sq E (630) Wood Dale Butzon, OD, Steve P 311 N Walnut Ave Ste (630) Woodridge Prentice, OD, Leo 7451 Woodward Ave Ste (630) September 2005
5 CompBenefits Insurance Company 2-Tier Enrollment Card Enrollment Card (Please print or type) CompBenefits Insurance Company Effective date of coverage: / / Date of employment: / / Employer: County of DuPage Division: Group #: You Last Name First Name MI Address City State Zip Social Security # / / Date of birth: / / Sex: F M Status: Single Married Your Family: Are you enrolling dependents in the? Yes No Are the same dependents covered under your employee medical plan? Yes No Please list the full name, sex, and date of birth of each family member to be covered by this plan: Date of Birth Last Name First Name MI Sex (mo/day/year) Your Spouse: F M / / Your Child(ren): F M / / F M / / F M / / I authorize payroll deductions (per month or per pay period) for: Employee Only: $ 5.74 or Employee + Family: $ $13.70 I agree to stay in the for the entire enrollment period, assuming I stay employed with this employer. I understand that future rates for 12-month renewals of this plan will be negotiated between my employer and CompBenefits Insurance Company. I hereby consent, personally and on behalf of any family members enrolled, to the unrestricted release of my/our vision records maintained by participating providers to CompBenefits Insurance Company for, but not limited to, claims verification and quality assessment review, and to any other participating providers who may be or become involved in my/our vision care. Date: Signed: PLEASE NOTE: Any person who knowingly, with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. VCP # 12-2T 10/00 006V2T 6/03
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