Vision Benefits. January 2013

Transcription

1 Vision Benefits January 2013 As a benefits-eligible associate at Advocate, you have the opportunity to choose optional coverage providing benefits for vision care services. This coverage featuring primary benefits and secondary discounts provides access to the services of one of the nation s biggest and best vision care networks: EyeMed Vision Care. The EyeMed Vision Care network includes thousands of private care practitioners as well as national retailers such as LensCrafters, most Pearle Vision locations, most Sears Optical locations and Target Optical. Two-part coverage You can select vision coverage for yourself and your eligible family members. This two-part plan is designed to provide you and your family comprehensive vision benefits and great customer service at a competitive price. Primary benefits help cover the cost of the most common types of vision care services, including annual comprehensive eye exams, frames, lenses or contact lenses, as well as benefits for traditional LASIK and PRK vision correction procedures. Many of the plan s primary benefits are subject to a onceevery-12-months limitation. Secondary discounts provide additional savings once your funded benefit is exhausted, enabling you to purchase eyewear and accessories for the balance of the year at a discount up to 45% off the retail price at EyeMed provider locations. For example If you purchase a set of eyeglass frames for yourself, you will receive an allowance of $130 toward the cost of the frames; you will pay 80% of any cost over and above this amount. If you purchase a second set of eyeglass frames for yourself that same year, you will receive a 20% discount on the cost of those frames (and any other frames you buy for yourself during the balance of the year). You will receive 40% off a complete pair of eyeglasses consisting of a frame and lenses. You may order replacement contact lenses at a discounted rate through the EyeMed Web site (see Contact Lens Benefit on page 3). This online reordering feature does not apply to the purchase of your initial pair of contact lenses, which you must purchase from your eye care provider to ensure proper fit and follow-up care. For a listing of EyeMed providers, visit EyeMed s Web site and choose the Select Network or call EyeMed benefits: A closer look The primary benefits and secondary discounts provided by the Advocate Vision Plan are summarized on the following pages. Remember: The plan s secondary discounts feature provides additional protection if, within any 12 month period, you use up an available primary benefit up to 45% off the retail price at EyeMed provider locations on subsequent purchases within that 12 month period.

2 Primary Benefits Exam: Your Cost when you use an EyeMed network provider Your Cost when you DON T use an EyeMed network provider With dilation as necessary $10 Copay Up to $30 Contact Lens Fit and Follow-up: Standard 1 Up to $40 N/A Premium 2 10% off retail price N/A Frames: Standard Plastic Lenses: $0 Copay; $130 Allowance, 20% off balance over $130 $45 Once every 12 months: Single Vision $10 Copay Up to $25 Bifocal $10 Copay Up to $40 Trifocal $10 Copay Up to $55 Standard Progressives $75 Copay Up to $40 Premium Progressives $75, 80% of Charge less $120 Allowance Up to $40 Lens Options: Paid by you and added to base price of lens: Tint (Solid and Gradient) $15 N/A UV Coating $15 N/A Standard Scratch-Resistance $0 Up to $5 Standard Polycarbonate $0 (dependents < 19), $40 (all other) Up to $5 Standard Anti-Reflective $45 N/A Other Add-Ons and Services 20% off Retail Price N/A Contact Lenses: Once every 12 months materials only: Conventional $0 Copay, $150 Allowance; 15% off balance over $150 Up to $100 Disposables $0 Copay, $150 Allowance; plus balance over $150 Up to $100 Medically Necessary $0 Copay, Paid In Full Up to $200 LASIK and PRK Vision Correction Procedures 3 : 15% off retail price OR 5% off promotional pricing N/A Secondary Discounts Complete Pair of Eyeglasses Frames Standard Plastic Lenses 1 Your Cost 40% off retail price including add-ons 20% off retail price 20% off retail price including add-ons 1 Standard contact lens fitting spherical clear contact lenses in conventional wear and planned replacement. Examples include but not limited to disposable, frequent replacement, etc. 2 Premium contact lens fitting all lens designs, materials and specialty fittings other than standard contact lenses. Examples include toric, multifocal, etc. 3 Members also receive 15% off the retail price or 5% off the promotional price for LASIK or PRK from the U.S. Laser Network, owned and operated by LCA Vision. Since LASIK or PRK vision correction is an elective procedure, performed by specially trained providers, this discount may not always be available in your immediate location. For a location near you and the discount authorization, please call 877.5LASER6. 2

3 Contact lens benefit EyeMed s contact lens benefit is simple and easy-to-use. Your EyeMed coverage includes an annual allowance toward the purchase of conventional or disposable contact lenses. Medically necessary contact lenses, when pre-approved by EyeMed Vision Care, are paid in full at in-network providers. This allowance is applied toward the actual contact lens materials only. Standard fit and follow-up costs are capped at $40, and premium fit and follow-up costs are discounted 10% (see definitions on previous page). You are responsible for any balance remaining after these fees are subtracted from the allowance. If you are purchasing conventional contact lenses, you will receive an additional 15% off the balance. For example Let s say it is time for your annual eye examination and you choose to visit an EyeMed provider. Here s how the benefit works: You pay the initial $10 co-payment amount for the in-network benefit which will cover the fully funded comprehensive eye examination and provide a $150 allowance for your contact lenses. You choose to purchase a one-year supply of disposable Acuvue Advanced contact lenses with a retail value of $175. The cost of the standard fit and follow-up examination is $30. The out-of-network reimbursement excludes the fitting fees and the $100 re-imbursement only covers the cost of the materials. EyeMed ID Cards EyeMed provides associates who enroll in the Advocate Vision Plan two ID cards. These cards are included in the EyeMed materials mailed to your home when you enroll. If you wish to use your vision care benefits before receiving your ID cards, simply identify yourself as an EyeMed member when you visit a participating provider; to verify eligibility you may be asked to provide your date of birth, your member ID or your Social Security number. You can request an additional or replacement card online at or by calling Additional purchases/out-of-pocket discounts If you elect this coverage, you should know that: You will receive a 20% discount on items not covered by the plan at network providers; this discount does not apply to the professional services of an EyeMed provider or contact lenses and cannot be combined with any other discounts or promotional offers discount. You also will receive a 40% discount on the purchase of a complete pair of eyeglasses and a 15% discount off conventional contact lenses. Allowances are one-time use benefits; no remaining balance. After initial purchase, replacement contact lenses may be obtained via the Internet at substantial savings and mailed directly to the member. The contact lens benefit allowance is not applicable to this service. Your out-of-pocket expense at the time of service can be broken down as follows: $175 - $150 (allowance) = $25 + $10 (co-payment) + $30 fitting fee = $65 This is your out-of-pocket expense for exam and contact lens purchase. 3

4 Ordering replacement contact lenses Through EyeMed, you have an easy way to order replacement contact lenses if you need to purchase an additional supply before the calendar year is up. You can order replacement contacts at very competitive prices at the EyeMed Web site and have them mailed directly to your home. At EyeMed, quality of care is the first priority. So online ordering is available for replacement contact lenses only; you must use your primary benefits for your initial purchase of contact lenses from an EyeMed provider at the time of your contact lens exam. This will help ensure that you receive all appropriate follow-up visits to confirm a proper fitting of your prescription contact lenses. Finding an EyeMed provider If you need some help finding an optician, optometrist, ophthalmologist or retail location that is a member of the EyeMed provider network, you can: Call to talk with an EyeMed Member Services representative. Someone will be available to talk with you Monday Saturday between 7 am and 10 pm CT, or Sunday between 10 am and 7 pm CT. Call to use the WiseEyes Interactive Voice Response System to get the name, address and telephone number of EyeMed providers in your area. This system is available daily 24 hours per day, excluding planned maintenance. Access choose the Select Network option to review a list of provider names, addresses and phone numbers, and to print out driving directions and a map. When ordering replacement contact lenses, you will need to enter all appropriate shipping and billing information, as well as your EyeMed provider s name and the brand, type and amount of lenses you wish to purchase. For quality of care purposes, the EyeMed provider will need to approve your order. Upon the prescription release, the requested lenses will be conveniently and immediately shipped to your home. Because this is a replacement lens program, the contact lens allowance or discount from the plan benefit does not apply. 4

5 Other information Limitations/exclusions The Advocate Vision Plan will not pay benefits for the following services and materials: Orthoptic or vision training, subnormal vision aids and any associated supplemental testing Medical and/or surgical treatment of the eye or supporting structures Corrective eyewear required by an employer as a condition of employment, and safety eyewear unless specifically covered under the plan Services provided as a result of any Workers Compensation law Plano non-prescription lenses and non-prescription sunglasses (except for 20% discount) Two pairs of glasses in place of bi-focals, or Lost or broken materials. Benefits are not provided for services or materials arising from orthoptic or vision training, subnormal vision aids and any associated supplemental testing, medical and/ or surgical treatment of the eye, eyes or supporting structures, services provided as a result of any Workers Compensation law, corrective eyewear required by an employer as a condition of employment and safety eyewear unless specifically covered under the plan, plano non-prescription lenses and non-prescription sunglasses (except 20% discount), two pair of glasses in lieu of bifocals and aniseikonic lenses. Filing claims If you receive vision care services from an EyeMed provider, you will not need to file a claim form. You will simply pay the cost of services or eyewear that exceeds the plan s allowance, and any applicable co-payments. However, if you receive your services from a provider who is not a member of the EyeMed network, you will need to pay the full cost of any services you receive and/ or eyewear that you purchase at the time of service. You will then need to file an Out-of-Network Claim Form, along with an itemized copy of your receipt, to receive benefits that may be payable from the plan. A copy of the EyeMed claim form is available online at (go to Advocate Benefits Online/Resources & Forms/Forms). Changing coverage Because the contributions you pay for this coverage are deducted from your pay on a pre-tax basis, you cannot change your coverage other than during annual benefits enrollment unless you experience a qualified life status change. You can learn more about what constitutes a qualified life status change online at (go to Advocate Benefits Online/Status Change). About this summary This summary highlights certain features of the Advocate Health Care Vision Care Plan. Advocate reserves the right, at its discretion, to amend, change or terminate any of its benefit plans, programs, practices or policies, as it requires. Nothing in this summary shall be construed as creating an expressed or implied obligation on Advocate s part to maintain such benefit plans, programs, practices or policies. 5 Advocate Health Care 10/12 MC 1986