Vision Care Plan Plan Year

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1 Vision Care Plan 2016 Plan Year

2 This Coverage Information Section of the Summary Plan Description ( SPD ) for Sprint Vision Care Plan has been created using simple terms and in an easy-to-understand format This Section will use the terms we, our or us to refer to Sprint or its wholly-owned US subsidiary and to you or your to refer to our employees (and their Eligible Dependents as applicable) eligible to participate in the Vision Care Plan as described below. Sprint intends to continue the Vision Care Plan. However, Sprint reserves the right to change or discontinue any or all benefits under this plan, at any time. In case of any conflict between the SPD or information from Surency Vision and the Sprint Welfare Benefit Plan for Employees, the Sprint Welfare Benefit Plan for Employees governs. In case of any conflict between the Vision Care Plan SPD and information from Surency, the Vision Care Plan SPD governs. What Is Inside Your Sprint Vision Care Plan 2 A Look At Vision Care Coverage 2 Eligibility & Enrollment 5 How Vision Care Works 5 Finding Providers 6 What Is Covered 6 Eye Exams 6 Lenses And Frames 6 Contact Lenses 7 Laser Eye Surgery 7 Low Vision Benefits 9 Coordinating With Medical Coverage 11 Coverage Under An HMO 11 What Is Not Covered 11 Special Services And Supplies 12 Filing Vision Care Claims 12 If Your Provider Is Not A Member Of The Network 12 Disputing Your Coverage or Claim Determination 13 Helpful Numbers 13 As Your Needs Change 13 When Coverage Ends 14 Other Important Information 14

3 Your Sprint Vision Care Plan On the job or at home good vision helps us perform at our best. Yet, while good vision is important, it is something most of us take for granted. Often, it is because we do not take the time to properly have our eyes examined. So, to encourage you and your family to see the benefits of healthy eye care, Sprint provides a Vision Care Plan offering. Surency Vision, a wholly-owned subsidiary of Delta Dental of Kansas, and EyeMed Vision Care has aligned to provide you with a vision program, offering the freedom to choose providers from both independent private practitioners and retail chains. The retail chains included in the EyeMed Sprint Access network are: LensCrafters, Pearle Vision, Target Optical, JCPenney Optical and Sears Optical. You and your family can save on vision exams, eyeglasses, contact lenses and laser eye surgery when you receive services from Surency Vision using providers in the EyeMed Sprint Access network. You may use any provider, but higher benefits are paid if you use eye care professionals in the EyeMed Sprint Access network. A Look At Vision Care Coverage Here is a look at the vision care coverage. Please be sure to read through this entire summary booklet for coverage details and important information. Service Network Provider Out-Of-Network Provider (You get reimbursed) Eye Exams (Once per calendar year) Plan pays 100%after $15 co-payment* Up to $45 Lenses (Once per calendar year) (Includes lenticular lenses, scratch resistant coating, ultraviolet coating, tints and dyes, and polycarbonate lenses for children under the age of 19)** Single Vision Lined Bifocals Plan pays 100% after $25 co-payment Plan pays 100% after $50 co-payment Up to $45 Up to $65 2

4 Lined Trifocals Plan pays 100% after $50 co-payment Up to $85 Up to $5 for tints and dyes Standard Progressive*** Frames (One pair per calendar year) Contacts (Once per calendar year) Lenses Plan pays 100% after $50 co-payment Plan pays 100% of allowable amount of $140; you will receive a 20% discount on the charges over the allowable amount; the plan also allows a 20% discount on non-prescription sunglasses and a 40% discount on an additional pair of glasses or prescription sunglasses Plan pays 100% for up to $140 once per calendar year for contact lenses Plan pays 100% after $25 co-payment for medically necessary contacts Up to $47 Up to $105 once per calendar year for contact lenses Up to $185 once per calendar year for medically necessary contacts Standard Contact Lens Fit and Follow Up The maximum you pay is $55 for standard lens fitting and follow up Premium Contact Lens Fit and Follow Up You receive 10% off retail for premium lens fitting and follow up 3

5 Laser Eye Surgery LasikPlus Center The featured provider provides greater discounts and extra value; The maximum you pay is: Traditional LASIK w/ Bladefree (enhancements up to one year) Traditional LASIK w/ Bladefree (enhancements for life) Custom or Wavelight LASIK w/ Bladefree $695 per eye* $1,395 per eye $1,895 per eye U.S. Laser Network Discounted rates available; The maximum you pay is: PRK $1,500 per eye** LASIK $1,800 per eye** Custo m LASIK $2,300 per eye** No discounts available (enhancements for life) *For vision that has a better than -2 prescription for nearsightedness (or better than -1 with astigmatism), and other restrictions may apply ** Prices do apply towards Custom PRK or Bladefree procedures Customer Service Surency Vision: Providers/Facilities Surency Vision together with EyeMed Vision Care, offer a network that includes more than 73, 000 retail and independent private practitioners at nearly 27, 000 locations. To locate a provider near you, visit Select the Sprint Access Network. *Co-payment is a predetermined amount that you pay directly to the doctor or other health care provider when you receive services. ** Member Preferred pricing on non-covered lens options (i.e. photochromic lenses, anti-reflective coating, premium progressive lenses, high index lenses, etc.) when using a network provider. ***Standard progressive lenses require a certain sized frame to allow enough vertical height to give a smooth transition from distance vision down to reading. Premium progressive lenses provide a wider reading area than standard progressive lenses. The lenses also have a high level of customization, allowing users to wear them with any frame. There is only one material co-payment when lenses and frames are purchased at the same visit. Surency Vision, together with EyeMed have arranged for members to receive PRK, LASIK and Custom LASIK at a discounted fee, which 4

6 could add up to hundreds of dollars in savings. See the Laser Eye Surgery section for more information. Surency Vision members have freedom of choice in selecting frames. Your benefits provide guaranteed savings whether you choose a frame that is covered or one that exceeds the plan allowance. If you choose a frame valued at more than the plan s allowance, the difference you will pay is based on Surency Vision s low, discounted member pricing when you use a network or retail provider. Surency Vision offers valuable savings including a 40% discount on non-covered pairs of prescription glasses (lenses and a frame). Services must be received within 12 months from the same provider who provided your last covered eye exam. You cannot be billed for more than $55 for your Standard contact lens Fit and Follow-up exams so that you may use your entire $140 contact lens benefits for materials. Eligibility & Enrollment For rules on who is eligible to be covered, enrollment, and effective dates of coverage, see the separate Eligibility & Enrollment Section SPD incorporated herein by reference on the Benefits Overview page of iconnect under the Summary Plan Descriptions (SPD) column. How Vision Care Works The Surency Vision network of eye care providers, featuring EyeMed s independent private practitioners and retail chains, works like other health care networks when you use network providers for your vision care services, you receive higher benefits. If you choose out-ofnetwork providers, limited benefits are paid. When you receive services, simply inform the provider that you have coverage with Surency Vision featuring the EyeMed Sprint Access plan and provide the personal information that is required (including your identification number and employer s name Sprint ). The EyeMed provider will confirm your membership and you will receive benefits. If you are not eligible for benefits at that time, the provider will communicate that to you. You also may verify benefit availability for you and your covered dependents prior to making your appointment by visiting the Surency Vision website at 5

7 Finding Providers Finding a network provider, either an independent private practitioner or a retail chain, is the first step towards maximizing your Surency Vision benefits. Two options to find a provider: Call Surency Vision s toll-free Member Services Support Line at: Visit the Surency Vision website at What Is Covered Using in-network providers When you use participating eye providers, you will receive a higher level of benefit coverage. A nationwide network of vision care providers, both independent private practitioners and retail chains provides your Sprint vision care coverage. Surency Vision covers most vision care expenses and pays higher benefits if you use network providers. Here is how Surency Vision covers vision care services and supplies. Eye Exams Surency Vision covers routine eye exams once per calendar year. When performed by an EyeMed Sprint Access network provider, Surency Vision fully covers the cost of the eye exam after you pay a $15 co-payment. If you use an out-of-network provider, Surency Vision reimburses up to $45 towards your eye exam. Lenses And Frames Surency Vision provides benefits for lenses and frames once per calendar year, after you pay a $25 co-payment toward the cost of single vision lenses or a $50 co-payment toward the cost of bifocal, trifocal and standard progressive lenses. When you use an EyeMed Sprint Access network provider, lenses (single vision, lined bifocal, lined trifocal, lenticular, and lens coating such as scratch resistant, ultraviolet, and polycarbonate lenses for children under the age of 19) are covered in full. A $40 co-payment towards polycarbonate lenses for individuals over the age of 19 applies. Frames are covered 100% up to the retail frame allowance of $140. If you use an out-of-network provider, materials are covered up to the following limits: Materials (Lenses And Frames) Plan Pays With Out-of-Network Providers Lenses (once per calendar year) Single vision Lined bifocal Lined trifocal Standard Progressive 6 up to $45 up to $65 up to $85 up to $65

8 Frames (one pair per calendar year) up to $47 Optional features that are not medically necessary but are sometimes chosen for cosmetic reasons (such as progressive lenses, antireflective coating, blended lenses, oversized lenses 61 mm or larger or special lens tints) are discounted for Surency Vision members when using an EyeMed Sprint Access network provider. See Special Services And Supplies for details. Contact Lenses Benefits are provided for both elective and medically necessary contact lenses. When using an EyeMed Sprint Access network provider, if you elect to order contact lenses instead of eyeglasses, you will have an allowance of up to $140 once per calendar year for the contact lenses. A Standard contact lens Fit and Follow-up exam will be covered after $55 co-pay. You will receive 10% off retail prices if receiving a Premium contact lens Fit and Follow-up exam. When using an out-of-network provider, the allowance when purchasing contact lenses (instead of eyeglasses) is up to $105 once per calendar year after you pay a $15 co-payment for a comprehensive routine eye exam. A contact lens eye exam or fit and follow-up exam is a special exam to ensure the proper fit of your contacts and evaluating your vision with the contacts. Medically necessary contact lenses may be covered in full (with an in network provider) after a $25 co-payment when submitted and preapproved by Surency Vision (up to $185 with an out-of-network provider) when needed due to: Cataract surgery; Extreme visual acuity problems that cannot be corrected with glasses; Anisometropia different refractive power in each eye; and Keratoconus protrusion of the cornea. Dollar allowances are for two lenses if you need only one lens, the allowance is one-half the amount listed. In addition, if you order contact lenses one year, you can order eyeglass lenses and frames at any time during the next calendar year. Laser Eye Surgery Surency Vision, together with EyeMed have arranged for members to receive PRK, LASIK and Custom LASIK at a discounted fee, which could add up to hundreds of dollars in savings. Discounts vary by location, but will average 15 percent off of the contracted laser center's usual and customary price. Additionally, if the participating laser center is offering a temporary price reduction, Surency Vision 7

9 Eye Surgery More and more people are having vision correction surgery your vision care coverage provides benefits toward these types of procedures. members will receive 5 percent off of the promotional price. Through this program, the most you will pay for laser surgery is: For PRK LASIK Custom LASIK (Using wavelight technology only other technologies not covered under Custom LASIK) The Most You Will Pay Is Up To $1,500 per eye $1,800 per eye $2,300 per eye Surency Vision, together with EyeMed and U.S. Laser Network have arranged for members to receive even further discounts when having LASIK surgery through one of the LasikPlus Centers across the U.S. When using a LasikPlus Center, the maximum you will pay is: For Traditional Lasik w/ Bladefree (enhancements up to 1 year) Traditional Lasik w/ Bladefree (enhancements for life) Custom or Wavelight LASIK w/ Bladefree (enhancements for life) The Most You Will Pay Is Up To $695 $1,395 per eye $1,895 per eye Follow these steps to learn the facts and find out if it s right for you. 1. Contact U.S. Laser Network at: LASER6 to: Get details about the program and laser vision correction; Learn what to expect during surgery; Ask questions about the procedure; and Find a network provider in your area. 2. Confirm your eligibility before scheduling an appointment. Log on to or call Surency Member Services at Call your network provider to verify their participation in the program. 4. Schedule a complimentary screening with your network provider to learn more about laser vision correction. 8

10 If you decide to have laser vision correction, your network provider will make arrangements with one of the approved laser surgeons and centers. The network provider will also provide your pre-operative care*. Post-procedure care is coordinated between your Surency Vision network provider and your U.S. Laser network laser surgeon. * While the laser vision correction screening and consultation with your network provider is complimentary, if you have a pre-operative exam and do not proceed with the surgery, your network provider may charge an exam fee of up to $100. Low Vision Benefit The Low Vision benefit is available to Covered Persons who have severe visual problems that are not correctable with regular lenses and is subject to prior approval by Surency Consultants. Supplementary Testing Member Doctor Benefit Non Member Benefit Covered in Full Up to $ Complete low vision analysis/diagnosis which includes a comprehensive examination of visual functions, including the prescription of corrective eyewear or vision aids where indicated. Supplemental Care Aids Member Doctor Benefit Non Member Benefit 75% of Cost 75% of Cost Subsequent low vision aids as Visually Necessary or Appropriate. Copayment for Supplemental Aids: 25% payable by Covered Person. Benefit Maximum The maximum benefit available is $ (excluding Copayment) every two years. Non-Member Provider Benefit Low Vision benefits secured from a Non-Member Provider are subject to the same time limits and Copayment arrangements as described above for a Member Doctor. The Covered Person should pay the Non- Member Provider his full fee. The Covered Person will be reimbursed in accordance with an amount not to exceed what Surency would pay a Member Doctor in similar circumstances. NOTE: There is no assurance that this amount will be within the 25% Copayment feature. 9

11 Exclusions and limitations of Benefits Patient Options This Plan is designed to cover visual needs rather than cosmetic materials. When the Covered Person selects any of the following extras, the Plan will pay the basic cost of the allowed lenses, and the Covered Person will pay the additional costs for the options: Optional cosmetic processes. Premium progressive lenses. Anti-reflective coating. Color coating. Mirror coating. Blended lenses. Cosmetic lenses. Laminated lenses. Oversize lenses. Progressive multifocal lenses. Certain limitations on low vision care. A frame that costs more than the Plan allowance. Contact lenses (except as noted elsewhere herein). Not Covered Under the low vision benefit, there is no benefit for professional services or materials connected with: Orthoptics or vision training and any associated supplemental testing; plano lenses (less than a ±.50 diopter power); or two pair of glasses in lieu of bifocals; Replacement of lenses and frames furnished under this Plan which are lost or broken, except at the normal intervals when services are otherwise available; Medical or surgical treatment of the eyes; Corrective vision treatment of an Experimental Nature; Costs for services and/or materials above Plan Benefit allowances; Services and/or materials not indicated on this Schedule as covered Plan Benefits. 10

12 Coordinating With Medical Coverage Is Vision Covered Elsewhere? Other vision coverage may be available to you be sure to check over your health care provider information for vision care benefits. If you have an accidental injury or illness that affects your eyesight, coverage may be provided by your medical provider. Submit the claim to Surency Vision for consideration, after your medical provider has processed the claim. Coverage Under An HMO If you are enrolled in a Health Maintenance Organization (HMO), your coverage may include basic vision care benefits separate from the coverage provided under the Vision Care option of the Sprint Plan. Vision expenses not covered by the HMO may be submitted if you are a plan participant. What Is Not Covered Vision care coverage does not cover the following expenses: Tax Considerations If you have significant non-reimbursed vision care expenses during a calendar year, those expenses may be tax deductible consult your tax advisor if this applies to you. Services covered by your medical provider or another benefit plan; Services or supplies payable under Workers Compensation or selfemployment laws; Services performed or supplies ordered before your coverage is effective; Services or supplies provided by an individual who is not an optometrist, ophthalmologist, or dispensing optician; Completing insurance forms; Orthoptics, vision training or supplemental testing; Nonprescription sunglasses and subnormal vision aids; Replacing lost, stolen or broken lenses or frames, except when within the normal interval allowed under this coverage; Duplicate glasses, lenses or frames; Cosmetic materials; Services or supplies connected with plano lenses, or two pairs of glasses instead of bifocals; More than one eye refraction within a calendar year; More than one pair of eyeglass lenses or contact lenses within a calendar year; More than one set of frames within a calendar year; Medical or surgical treatment, drugs or medicines; Free services or supplies; Experimental services or supplies; 11

13 Custom LASIK procedures unless using the wavefront technology; all other technologies not covered under Custom LASIK; Service agreements (insurance for loss or replacements); Services or supplies for a disease, defect or injury resulting from an act of war; and Services or supplies for which benefits are payable through a government health care program. Special Services And Supplies Confused About What Is Covered? If you have questions about whether an expense is covered, call us or check out the website on i- Connect. Sprint s Vision Care Plan is designed to cover visual needs rather than cosmetic materials. If you select any of the following extras, you will be responsible for the cost of these options: Blended lenses; Premium Progressive lenses; Anti-reflective coating; Oversized lenses; Tinted lenses except pink #1 or pink #2; Progressive multifocal lenses; Laminating of lens or lenses; and A frame that costs more than the coverage allowance. Note: member providers provide discounts for these special services and supplies. Filing Vision Care Claims As long as you use an EyeMed Sprint Access network provider, there are no claims to file the provider does it for you. If Your Provider Is Not A Member Of The Network If you use an out-of-network provider, you must pay for the services and submit an itemized receipt to Surency Vision with the following information: Itemized statements of services received; Covered member s Identification number; Covered member s name, phone number and address; Member s employer; and Patient s name, relationship to member and date of birth. Out-of-network claims must be submitted within six months from the date the expenses are incurred in order to be considered for reimbursement. 12

14 The following steps are the most efficient way for members to access their out-of-network Benefit: 1. Visit for an Out-of-Network Claim Form. 2. Schedule an appointment with your provider. 3. Pay for vision care services and materials at the point of care and obtain an itemized receipt from the provider office. 4. Submit the completed claim on the EyeMed Out of Network claim form, attaching the itemized receipt from the provider. 5. Mail claims for services received from out-of-network providers to: EyeMed Vision Care Attn: Out of Network (OON) Claims P.O. Box 8504 Mason, Ohio A reimbursement check will be sent to you for benefits based on the out-of-network EyeMed Benefit levels. Disputing Your Coverage or Claim Determination If you or your dependent(s) are denied participation in, or eligibility to participate in, a welfare plan, or if you disagree with a claim determination, you have the right to file an appeal to request reconsideration. See the Legal Information document for important information on how to appeal and the applicable timeframes associated with the appeals process. Helpful Numbers Customer Service Number: Surency Vision: LasikPlus Center: U.S. Laser Network: LASER LASER6 To find providers online Surency Vision website: As Your Needs Change In certain situations, you may change your enrollment in your Sprint Vision Care Plan see the Life Events Section that is also part of a Summary Plan Description for the Plans, incorporated herein by reference on the Benefits site of i-connect under Summary Plan Descriptions. 13

15 When Coverage Ends For information on when your coverage under the Vision Care Plan ends, see the separate Eligibility & Enrollment Section of the SPD incorporated herein by reference on the Benefits site of i-connect under Summary Plan Descriptions. Other Important Information For other important information about the Vision Care Plan s Plan Sponsor and Administrator, participating employers, Plan identification, service of legal process, ERISA rights, including claims and appeals procedures, and other legally-required notices regarding the Vision Care Plan, see the separate Legal Information section of the SPD incorporated herein by reference on the Benefits site of i- Connect under Summary Plan Descriptions. 14

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