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Reference ID: 1004268201012022Vision Benefit HighlightsPediatric/Adult Vision SML PPO Stnd Med $0PEDIATRIC BENEFITSCovered Services (Calendar Year) Your Costs (You pay)Exam In-Network Out-of-NetworkRoutine Eye Exam at Davis Participating Providers (1 exam/year)No charge Not coveredRetinal Imaging $39 Not covered Lenses (1 pair/year) In-Network Out-of-NetworkSingle Vision Lenses No charge Not coveredBifocal Lenses No charge Not coveredTrifocal Lenses No charge Not coveredLenticular Lenses No charge Not covered Lens Options In-Network Out-of-NetworkProgressive Lenses - Standard/Premium/Ultra/Ultimate$50/$90/$140/$175 Not coveredPolycarbonate Lenses - Single/Multifocal1$35 Not coveredDigital/Intermediate Lenses $30 Not coveredPhotochromic Lenses - Single/Multifocal $5 Not coveredPhotosensitive Lenses - Single/Multifocal $70 Not coveredHigh-Index 1.67 / High-Index 1.74 Lenses $55/$120 Not coveredBlue Light Lenses $15Not coveredPolarized Lenses $75Not coveredLens CoatingsTinted Plastic Lenses No chargeNot coveredUV-Coated Lenses No chargeNot coveredScratch-Resistant Lenses - Single/Multifocal $5 Not coveredScratch-Protection Plan - Single/Multifocal $20/$40 Not coveredAnti-Reflective Coating - Standard/Premium/Ultra/Ultimate$35/$48/$60/$85 Not covered Frames (1 pair/year) In-Network Out-of-NetworkCollection Fashion Frames No chargeNot coveredCollection Designer Frames No chargeNot coveredCollection Premier Frames No chargeNot coveredNon-Collection Frames Not covered Not coveredAdditional Visionworks Frames Option Up to $150 Allowance (plus a 20% discount on overage)2Not covered
Reference ID: 1004268201012022Contact Lenses (in lieu of glasses) (1 pair/year)In-Network Out-of-NetworkCollection Contact Lenses Evaluation, Fitting & Follow-Up CareNo charge Not coveredCollection Contact Lenses Disposable Boxes/Multipacks: 4 per yearPlanned Replacement Boxes/Multipacks: 2 per yearNot coveredNon-Collection Standard Contact Lenses Evaluation, Fitting & Follow-Up CareNot covered Not coveredNon-Collection Specialty & Disposable Contact Lenses Evaluation, Fitting & Follow-Up CareNot covered Not coveredNon-Collection Contact Lenses Up to $150 Allowance Not coveredMedically-Necessary Contact Lenses3No charge Not covered ADULT BENEFITSCovered Services (Calendar Year) Your Costs (You pay)Exam In-Network Out-of-NetworkRoutine Eye Exam at Davis Participating Providers (1 exam/year)No charge Not coveredRetinal Imaging $39 Not covered Lenses (1 pair/year) In-Network Out-of-NetworkSingle Vision Lenses No charge Not coveredBifocal Lenses No charge Not coveredTrifocal Lenses No charge Not coveredLenticular Lenses No charge Not covered Lens Options In-Network Out-of-NetworkProgressive Lenses - Standard/Premium/Ultra/Ultimate$65/$105/$140/$175 Not coveredPolycarbonate Lenses - Single/Multifocal1$35 Not coveredDigital/Intermediate Lenses $30 Not coveredPhotochromic Lenses - Single/Multifocal $5 Not coveredPhotosensitive Lenses - Single/Multifocal $70 Not coveredHigh-Index 1.67 / High-Index 1.74 Lenses $60/$120 Not coveredBlue Light Lenses $15 Not coveredPolarized Lenses $75 Not coveredLens CoatingsTinted Plastic Lenses $15 Not coveredUV-Coated Lenses No charge Not coveredScratch-Resistant Lenses - Single/Multifocal $5 Not coveredScratch-Protection Plan - Single/Multifocal $20/$40 Not covered
Reference ID: 1004268201012022Anti-Reflective Coating - Standard/Premium/Ultra/Ultimate$40/$55/$69/$85 Not covered Frames (1 pair/year) In-Network Out-of-NetworkCollection Fashion Frames No charge Not coveredCollection Designer Frames $15 Not coveredCollection Premier Frames $40 Not coveredNon-Collection Frames Up to $130 Allowance (plus a 20% discount on overage)2Not coveredAdditional Visionworks Frames Option Up to $180 Allowance (plus a 20% discount on overage)2Not covered Contact Lenses (in lieu of glasses) (1 pair/year)In-Network Out-of-NetworkCollection Contact Lenses Evaluation, Fitting & Follow-Up CareNo charge Not coveredCollection Contact Lenses Disposable Boxes/Multipacks: 4 per yearPlanned Replacement Boxes/Multipacks: 2 per yearNot coveredNon-Collection Standard Contact Lenses Evaluation, Fitting & Follow-Up CareNot covered Not coveredNon-Collection Specialty & Disposable Contact Lenses Evaluation, Fitting & Follow-Up CareNot covered Not coveredNon-Collection Contact Lenses Up to $130 Allowance2Not coveredMedically-Necessary Contact Lenses3No charge Not covered 1Polycarbonate lenses for dependent children, monocular patients, and patients with prescriptions greater than or equal to +/6.00 diopters are covered at no cost.2Member is responsible for balance. Additional discounts not applicable at Walmart, Costco, or Sam's Club locations.3Covered with prior approval. This summary represents only a partial listing of benefits of the Vision Care Program described in this summary. If your employer purchases another program, the benefits may differ. Also, benefits may be further defined by the vision policy. As a result, this vision plan may not cover all of your vision or health care expenses. Read your contract/member benefit booklet carefully for a complete listing of terms and limitations of the program. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.ibx.com/SGBooklet or call 1-800-ASK-BLUE (TTY: 711).Benefits may be changed by Independence Blue Cross to comply with applicable federal/state laws and regulations.Administered by Davis Vision.Benefits underwritten or administered by QCC Insurance Company, a subsidiary of Independence Blue Cross - Independent licensees of the Blue Cross and Blue Shield Association. www.ibx.com
Y0041_HM_17_47643 Accepted 10/14/2016 Taglines as of 10/14/2016 Language Assistance Services Spanish: ATENCIÓN: Si habla español, cuenta con servicios de asistencia en idiomas disponibles de forma gratuita para usted. Llame al 1-800-275-2583 (TTY: 711). Chinese: 注意：如果您讲中文，您可以得到免费的语言协助服务。致电 1-800-275-2583。 Korean: 안내사항: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-800-275-2583 번으로 전화하십시오. Portuguese: ATENÇÃO: se você fala português, encontram-se disponíveis serviços gratuitos de assistência ao idioma. Ligue para 1-800-275-2583. Gujarati: ૂચના: જો તમે ુજરાતી બોલતા હો, તો િન:ુક ભાષા સહાય સેવાઓ તમારા માટ ઉપલધ છે. 1-800-275-2583 કોલ કરો. Vietnamese: LU Ý: Nu bn nói ting Vit, chúng tôi s cung cp dch v h tr ngôn ng min phí cho bn. Hãy gi 1-800-275-2583. Russian: : -, . .: 1-800-275-2583. Polish UWAGA: Jeeli mówisz po polsku, moesz skorzysta z bezpatnej pomocy jzykowej. Zadzwo pod numer 1-800-275-2583. Italian: ATTENZIONE: Se lei parla italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-800-275-2583. Arabic: : . 1-800-275-2583. French Creole: ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-800-275-2583. Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, magagamit mo ang mga serbisyo na tulong sa wika nang walang bayad. Tumawag sa 1-800-275-2583. French: ATTENTION: Si vous parlez français, des services d'aide linguistique-vous sont proposés gratuitement. Appelez le 1-800-275-2583. Pennsylvania Dutch: BASS UFF: Wann du Pennsylvania Deitsch schwetzscht, kannscht du Hilf griege in dei eegni Schprooch unni as es dich ennich eppes koschte zellt. Ruf die Nummer 1-800-275-2583. Hindi: : 1-800-275-2583 German: ACHTUNG: Wenn Sie Deutsch sprechen, können Sie kostenlos sprachliche Unterstützung anfordern. Wählen Sie 1-800-275-2583. Japanese: 備考：母国語が日本語の方は、言語アシスタンスサービス（無料）をご利用いただけます。 1-800-275-2583へお電話ください。 Persian (Farsi): : . 1-800-275-2583 . Navajo: D77 baa ak0 n7n7zin: D77 saad bee y1n7[ti’go Diné Bizaad, saad bee 1k1’1n7da’1wo’d66’, t’11 jiik’eh. H0d77lnih koj8’ 1-800-275-2583. Urdu: : .1-800-275-2583 Mon-Khmer, Cambodian: - 1-800-275-2583
Y0041_HM_17_47643 Accepted 10/14/2016 Taglines as of 10/14/2016 Discrimination is Against the Law This Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. This Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. This Plan provides: Free aids and services to people with disabilities to communicate effectively with us, such as: qualified sign language interpreters, and written information in other formats (large print, audio, accessible electronic formats, other formats). Free language services to people whose primary language is not English, such as: qualified interpreters and information written in other languages. If you need these services, contact our Civil Rights Coordinator. If you believe that This Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with our Civil Rights Coordinator. You can file a grievance in the following ways: In person or by mail: ATTN: Civil Rights Coordinator, 1901 Market Street, Philadelphia, PA 19103, By phone: 1-888-377-3933 (TTY: 711) By fax: 215-761-0245, By email: civilrightscoordinator@1901market.com. If you need help filing a grievance, our Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.