Group Vision Insurance SUMMARY OF BENEFITS

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1 Group Vision Insurance SUMMARY OF BENEFITS Sponsored By Salamandar Farms, LLC Effective Date: February 1, 2013 All Active Full-Time Salamander Farms Employees You may choose any provider. However, using providers participating in the network should lower your out-ofpocket expenses. A list of participating providers may be accessed at or by calling toll-free at Members may purchase mail order contact lenses online at a 10% discount. Through Laser Vision Network of America (LVNA), we can provide our members with access to discounted laser vision correction procedures. Members may choose an NCQA-credentialed surgeon from LVNA s nationwide network of more than 400 laser vision correction surgeons. Patient options, such as ultraviolet protection and progressive lenses, are offered at a 20% to 40% discount, which results in substantial member savings from the provider's usual and customary charges. Network 1 Out of Network 2 EXAM COPAY $10 Not applicable MATERIAL COPAY $25 Not applicable Service Frequencies based on the last date of service. Exam: 12 months Lenses: 12 months Frames: 24 months EYE EXAMINATION 100% Up to $40.00 EYEGLASS LENSES Single Lenses 100% Up to $40.00 Bifocal 100% Up to $60.00 Trifocal 100% Up to $80.00 Lenticular 100% Up to $80.00 As a value-added benefit, standard scratch-resistant coating is provided at no additional charge for all lenses covered in full. FRAMES 3 100% Up to $45.00 ELECTIVE CONTACT LENSES 4 Covered Contact Lens Selection (material copay applies) 100% Up to $ All other elective contact lenses (no copay) Up to $ Up to $ NECESSARY CONTACT LENSES 5 100% Up to $ Your Monthly plan costs Employee only $6.93 Employee and Spouse $12.79 Employee and Children $13.40 Family $20.05 This is an estimate of premium cost. Actual deductions may vary slightly due to rounding and payroll frequency. Eligibility Dependent - Unmarried dependent children may be covered to age 25. Employee A full-time employee actively at work. Vision LVC9 9/12

2 Benefits 1. Network Benefits: Exam and materials copays and patient options are paid to the network provider by the plan participant. 2. Out-of-Network Benefits: The plan participant pays full fee to the provider and the member submits a claim for reimbursement of services rendered up to maximum allowance. There are no copays. 3. Frame Benefit: Our generous frame benefit applies to virtually all of the frames on the market today, and most of those are covered-in-full, with no additional cost to the member, other than applicable copay. Plan participants receive a $ retail frame allowance for frames purchased at retail chain providers, and for any frame above $130.00, the member will only pay the difference. A 30% discount is applied in excess of the allowance. 4. Elective Contact Lenses: Contact lenses are provided in lieu of eyeglasses (lenses and frame). When purchasing from the Covered Contact Lens Selection, the benefit is covered-in-full (after copay if applicable). This includes: fitting/evaluation fees contacts (including up to 4 boxes of disposables, depending on prescription and plan selected) up to two follow-up visits. Contact lenses purchased with an out-of-network provider or outside of the Covered Contact Lens Selection, the materials copay does not apply, and the allowance is applied toward the fitting/evaluation fees. 5. Necessary contact lenses are determined at the eye care provider s discretion. If an out-of-network provider considers contacts necessary, members should ask their out-of-network provider to contact us concerning the reimbursement that we will make before they purchase such contacts. Exclusions The following services and materials are excluded from coverage under the Policy: Post cataract lenses; Non-prescription items; Medical or surgical treatment for eye disease that requires the services of a physician; Worker s Compensation services or materials; Services or materials that the patient, without cost, obtains from any governmental organization or program; Services or materials that are not specifically covered by the Policy; replacement or repair of lenses and/or frames that have been lost or broken; Cosmetic extras, except as stated in the Policy s Table of Benefits. Out-of-Network Claim submission To file a claim for reimbursement for Services rendered by a non-network Provider, provide the following information: Your itemized receipts; Subscriber name; Subscriber's identification number; Patient name; and Patient date of birth. Submit a claim by mail to: Claims Department Lincoln VisionConnect P.O. Box Salt Lake City, UT Submit a claim by fax to: (248) NOTE: This is not intended as a complete description of the insurance coverage offered. While benefit amounts stated in this summary are specific to your coverage, other items may summarize standard product features and not the specific features of your coverage. Controlling provisions are provided in the policy, and this summary does not modify those provisions or the insurance in any way. This is not a binding contract. A certificate of coverage will be made available to you that describe the benefits in greater detail. Should there be a difference between this summary and the contract, the contract will govern. The Lincoln VisionConnect program is marketed by The Lincoln National Life Insurance Company (Fort Wayne, IN), which does not solicit business in New York, nor is it licensed to do so. In New York, this program is marketed by Lincoln Life & Annuity Company of New York (Syracuse, NY). Both are Lincoln Financial Group companies. Affiliates are separately responsible for their own financial and contractual obligations. Lincoln VisionConnect is a registered trademark of Lincoln National Corporation. Lincoln VisionConnect insurance products (policy series VPOL.06, VPOL.06.TX) are underwritten by UnitedHealthcare Insurance Company, and in New York, United Healthcare Insurance Company of New York. Vision LVC9 9/12

3 Lincoln VisionConnect program How to utilize your vision benefits 1 Locate a participating provider by clicking Provider Locator on or by calling Review your benefits at before you visit a provider. 3 When you visit a provider, you may be asked for your date of birth and your unique number, such as your social security number. Note to providers: For more information about this vision plan, or to receive authorization for service, please visit us online at or call This card is not required for service and does not guarantee benefit eligibility.

4 Submit out-of-network claims to: Claims Department Lincoln VisionConnect P.O. Box Salt Lake City, UT Fax: (Claim cover sheet can be found on member website.) The Lincoln VisionConnect program is marketed by The Lincoln National Life Insurance Company (Fort Wayne, IN), which does not solicit business in New York, nor is it licensed to do so. In New York, this program is marketed by Lincoln Life & Annuity Company of New York (Syracuse, NY). Both are Lincoln Financial Group companies. Lincoln VisionConnect is a registered trademark of Lincoln National Corporation. Lincoln VisionConnect insurance products (policy series VPOL.06 and VPOL.06 TX) are underwritten by UnitedHealthcare Insurance Company, and in New York, UnitedHealthcare Insurance Company of New York. These companies are not Lincoln Financial Group companies. Affiliates are separately responsible for their own financial and contractual obligations. Order code: VIS-ID-BCD001 1/13

5 Lincoln VisionConnect Fully-Insured Vision How to locate a Vision provider 1. Go to 2. Select Provider Locator, listed on the top left side of the screen. 3. Next, click the Future Member button. 4. To find Vision providers located in your area, enter the zip code or city and state. 5. Click the Search button. Advance Search: The Advance Search function allows you to search for a provider by: Practice Name Provider s First Name and Last Name To nominate a Vision Provider: If your search does not locate the provider you prefer, you can nominate a provider. On the Provider Locator - Results page, click on the Click here link located at the top. Complete the form online, and click the Submit button. GLM LVC 2008 Lincoln National Corporation

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