FORD MOTOR COMPANY FORD MOTOR COMPANY

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1 Vision Benefit Plan Certificate of Coverage FORD MOTOR COMPANY Salaried Active Employees Ford Vision Benefit Web Site: FORD MOTOR COMPANY

2 Table of Contents WELCOME TO HERITAGE VISION PLANS page 2 SECTION I FORD MOTOR COMPANY BENEFIT PLAN Scope of Coverage Preferred Pricing Discount What's Not Covered page 3 page 4 page 4 SECTION II USING YOUR BENEFIT PLAN Using a Network Provider Using an Out-of-Network Provider Claims Appeals Unresolved Concerns FREQUENTLY ASKED QUESTIONS GLOSSARY OF EYEWEAR TERMS Different Types of Prescription Lenses Eyeglass Lens Materials Eyeglass Lens Coatings and Options page 5 page 6 page 7 page 7 page 8-10 page 11 page 12 page 13 MEMBER RIGHTS/PRIVACY PRACTICES page 14 Heritage Vision Plans 1

3 Introduction WELCOME Ford Motor Company ees! We are glad to have you as members of the Heritage Vision Plans family. Heritage is a vision benefit management company that is dedicated to providing exceptional service, world-class quality and an extensive provider network. Heritage is committed to the quality, reliability and service excellence that have made us successful since Our goal is to provide you with the best in eye care and service. We are providing this booklet to enable you and your covered dependents to make the best possible use of your valuable vision care benefit. If you have questions that are not answered here, please call us toll-free at , or us at corporate@heritagevisionplans.com. Cordially, Heritage Vision Plans, Inc. Heritage Vision Plans has developed this guide to help you receive maximum value from your vision benefit. This handbook covers important topics such as: what services are covered, accessing a provider, filing a claim, and member rights and privacy practices. Heritage Vision OpticalPlans 2

4 FORD MOTOR COMPANY BENEFIT PLAN Section I Eligibility Your eligibility and/or your dependent(s) eligibility to par- ticipate in this Plan is determined by Ford Motor Company. Scope of Coverage Your Scope of Coverage is determined by Ford. This section of the Vision Benefit Handbook will explain your plan benefit. The following chart indicates what services are covered, how often each covered service can be used, what you can expect to pay when receiving services from an in-network provider and what your reimbursement amounts will be when receiving services from an out-of-network provider. SERVICES COVERAGE FREQUENCY IN-NETWORK COVERAGE OUT-OF-NETWORK REIMBURSEMENT Comprehensive Eye Exam (Does not apply to Professional fees for Contact Lens Fitting) Once per Calendar Year 1 $10.00 Co-pay,100% Covered Reimbursed up to $30.00 Frames: (Choice of One) Standard Frames (All frames up to $ Retail) Premium Frames (All frames over $ Retail) Once per Calendar Year 1 $0.00 (100% covered, No Co-pay) $ Retail Allowance, No Co-pay A 20% Preferred Pricing Discount will be applied to all frame costs over $ Elective / Cosmetic Contact Lenses 2 $ Retail Allowance, No Co-pay eritage Optical Reimbursed up to $ Exam and Materials Benefit Frequency is once per Plan Year (January 1 st December 31 st ) 2 You are eligible for contact lenses OR glasses, not both, in any plan year. Reimbursed up to $30.00 Reimbursed up to $30.00 Covered Lenses / Per Pair: (Choice of One) Covered Material = Plastic Single Vision Reimbursed up to $30.00 Bifocal Once per Calendar Year $15.00 Co-pay,100% Covered Reimbursed up to $35.00 Trifocal Reimbursed up to $40.00 Progressive Standard Premium Covered Lens Options and Upgrades U.V. Protection Tint Polycarbonate Contact Lenses: (in lieu of eyeglasses) Once per Calendar Year 1 Once per Calendar Year 1 $15.00 Co-pay,100% Covered Member pays upgrade expenses over covered Standard Progressive ($15.00 Co-Pay Applies) 25% Discount applies to member s balance 100% Covered, No Co-pay Reimbursed up to $50.00 The Contact Lens Benefit is in addition to the Comprehensive Eye Exam. The Covered Standard Contact Lens Fitting Fee is only applicable if contact lenses are selected as the material benefit. Standard Contact Lens Fitting 2 (All Lens Types including Disposables) Medically Necessary 2 Contact Lenses & Fitting (Contact Lenses Prescribed to treat specific Medical Conditions or Diseases of the eye) Once per Calendar Year 1 $0.00 (100% covered, No Co-pay) (Member pays all CL expenses over $105.00) $15.00 Co-pay, Then covered in full up to ($250) Approved U&C Amount (Requires Prior Approval & Review for Medical Necessity) N / A N / A N / A N / A Reimbursed up to $50.00 Heritage Vision Plans 3

5 Preferred Pricing Discounts Members will receive a Preferred Pricing Discount, from Heritage Participating Providers, on: Non-covered Lens Options and Material Upgrades 2nd Pair of Prescription Eyeglasses or Sunglasses Lasik Surgery 25% Discount off Retail Prices 25% Discount off Retail Prices 15% Discount on retail fee charged at designated locations 2. 2 Designated Lasik Provider Locations can be found at These Discounts may not be combined with any other discounts or promotional offers, and the discounts do not apply to professional services (except Lasik Surgery discount) rendered by the provider or to contact lenses. Retail prices may vary by provider location. What s Not Covered Products and services not covered under the plan include: Non-prescription lenses Two pairs of glasses instead of bifocals Lenses and frames furnished under this plan, which are lost or destroyed Parts or repair of frame not covered under manufacturers' warranty Medical or surgical treatment of the eyes, with the exception of the discount for Lasik Surgery. Drugs or medications Corrective vision services, treatments, and materials of an experimental nature Services not visually necessary Industrial (3mm) safety lenses and safety frames with side shields Any services not specified in Ford Motor Company's Scope of Coverage Heritage Optical Vision Plans 4

6 Section II USING YOUR BENEFIT PLAN Using a Network Provider Here are the steps to take: 1. Select a doctor/provider from the list of network providers. The list can be accessed on our Web site: or by calling our Interactive Voice Response (IVR) System toll-free at: The Interactive Voice Response System is available seven days a week, 24 hours a day. 2. Make an appointment with the doctor/provider of your choice. When calling to make an appointment, identify yourself as a Heritage Vision Plans member and your group as: Ford Motor Company - Salaried Employees, Retirees and Surviving Spouses.. The doctor will ask for your ID number and (Patient's) Birth Date. As a Heritage Vision Plans member, you will maximize benefits and reduce out-of-pocket costs by choosing to visit an In-Network Provider. 3. The doctor/provider will verify your eligibility and/or eligibility of dependents. 4. When the examination is complete and you and/or your eligible dependents have been fitted for any necessary glasses or contact lenses, the doctor/provider will explain any additional charges you may have to pay. 5. The doctor/provider will take care of all the paperwork. There are no claim forms for you to complete. Heritage Optical Vision Plans 5

7 Using an Out-of-Network Provider You do have the option of visiting an out-of-network provider. If you choose this option, follow these steps: 1. Make an appointment with the doctor/provider of your choice. 2. When the examination is complete and you and/or your eligible dependents have been fitted for any necessary eyeglasses or contact lenses, you will pay the full charges for the exam and eyeglasses or contacts. 3. You will need to request an itemized receipt from the doctor/provider containing the following information: Ford Member's name and mailing address Ford Member's ID number Ford Motor Company identified as the plan sponsor Patient's name, date of birth and relationship to the Ford Member Service and material received and dates received Type of lenses the patient received (single vision, bifocal, trifocal, Progressive, etc.) 4. Mail the itemized receipt to: Heritage Vision Claims c/o National Vision Administrators ATTN: Ford Vision Claims Reimbursement P.O. Box 2187 Clifton, NJ The itemized receipt serves as your claims form for reimbursement. 5. To be considered for reimbursement, claims must be filed within six months of the date services were completed. Heritage Vision Plans 6

8 Section II continued 6. Heritage will send you a reimbursement check for up to 6. the total of all applicable amounts listed under the out-ofnetwork reimbursement column in the chart on Page 3 of of this booklet. Claims Appeals If a claim is denied, in whole or in part, Heritage will notify you of the reasons for denial. Within 60 days after the date of the denial notice, you may make a written request for review of the denial. The request must include any and all supporting documentation. The claim will be reviewed and you will be notified of the decision. Submit claim appeals to: Heritage Vision Plans, Inc. ATTN: Claims Appeal Manager One Woodward Avenue, Suite 2020 Detroit, MI Unresolved Concerns If you are not satisfied with Heritage Vision Plans' resolution of any customer service issue you may have, please contact your Human Resources Department representative. After exhausting all avenues to have your concerns satisfactorily addressed, you may contact: Health Plans Division Department of Insurance and Financial Services (DIFS) 611 W. Ottawa, Third Floor P.O. Box Lansing, MI Heritage Vision Plans 7

9 FAQ FREQUENTLY ASKED QUESTIONS Q: Do How I need does an the ID wholesale card? pricing apply to the A: FREQUENTLY Premium No, you do Frame ASKED not need Allowance? QUESTIONS ID card. When you call A: Frames for an appointment exceeding the with plan a allowance provider, (Premium the provider Frames) Q: outlined Do will I verify need in your the an Ford ID eligibility. card? Vision Plan The are provider charged will by ask the for pro- A: vider your No, you based Member do on not the ID need following number, an ID formulary: which card. When is your you social call security for an appointment number, and with the a Patient's provider, Date the provider of Birth. Example: will verify your eligibility. The provider will ask for Q: How your A Member can Frame I with obtain ID an number a list which wholesale of is vision your cost would Social carebe providers priced in as your follows: Security Number. network? A: Heritage Vision Plans wholesale offers cost a provider locator on Q: How our Web can site: I obtain frame allowance a list of care providers and by calling your toll-free network? difference number: A: Heritage Vision Plans offers a provider locator on Q: Where our Web do site: difference I get a claim plus 20% form ( 6.80) to submit $ and forby reimbursement? calling The our patient toll-free would number: responsible for A: If you visit an in-network provider, there is no claim Q: Where How form to does submit. the I get contact The a provider claim lens benefit form will handle to work? submit all of the for A: reimbursement? Your paperwork in-network and plan will submit covers the all contact claim. lens If you (non-medically visit an necessary) A: costs out-of-network If you up visit to an in-network provider, every you provider, plan must year. get there The an contact is itemized no claim lens fitting receipt form fee to from is submit. covered the provider The under provider the and benefit, submit will handle that the receipt all contact of the tolenses are Heritage paperwork covered Vision and up to will Plans submit for every reimbursement. the claim. plan year. If you The visit an receipt out-of-network will serve provider, as the claim you must form. get Please an itemized see Q: What are medically necessary contact lenses? Page receipt web 6 from site: for a the complete provider description and submit of that what receipt the to A: Medically itemized Heritage receipt necessary Vision must Plans contacts contain. for reimbursement. are prescribed to The correct the better receipt eye will to serve 20/70 as due the to: claim form. Please see Q: Where Page 1) cataract 6 do for a I complete surgery send my description itemized of receipt what thefor reimbursement? itemized 2) extreme receipt visual must acuity contain. problems not correctable with A: Send the spectacle itemized lenses receipt to: Q: Where 3) Heritage significant do Vision I send anisometropia Claims my itemized receipt for reimbursement? 4) c/o keratoconus National Vision Administrators A: Prior Send ATTN: approval the itemized FORD is required Vision receipt Claims for to: medically Reimbursement necessary contact lenses. P.O. Heritage Box 2187 Vision Plans Clifton, ATTN: Instaset NJ Claims Reimbursement Livernois Avenue, Suite B Q: Do Detroit, all optical MI locations have the same frames to choose from? A: No, the frames will differ by location, but each location will have a wide variety of styles to choose from. Heritage Vision Plans 9 Heritage Vision Plans 8

10 FAQ continued Q: If I decide to pay an in-network provider for ser- vices instead of using my benefit, can I be reimbur- sed? How much money would I be reimbursed? A: If you decide to pay an in-network provider for services out of your own pocket, for example, to take advantage of a retail sale or promotion, you would be reimbursed according to the out-of-network reimbursement rate in the schedule on page 3 of this member handbook. When filing the claim for reimbursement you must follow the out-of-network reimbursement procedure outlined on page 6-7 of this member handbook. You will not be reim- bursed the retail amount charged by the provider. Q: How can my present doctor join the network? A: You may refer your doctor to us for inclusion in our network. Request that your doctor contact our Director of Provider Relations at ext for an application packet, or corporate@heritagevisionplans.com Q: Is Lasik a covered or partially covered benefit? A: Ford Motor Company members receive a 15% discount on Lasik Surgery at designated locations only. The locations can be found on our web site: Q: How do I know which of the toll-free numbers listed in this book to use? A: If you need information regarding eligibility or provider locations, use the toll free number. This will connect you to the Customer Service Center or IVR system. For all other member service needs, please use the toll free number. This will connect you to the Heritage Vision Plans administrative offices. Heritage Vision OpticalPlans 9

11 FAQ continued Q: Do all optical locations have the same frames to choose from? A: No, the frames will differ by location, but each location How will does have the a wide contact variety lens of benefit styles to work? choose from. Q: Q: How does the wholesale pricing apply to the A: Q: Do Your all in-network optical benefit locations covers all have contact the lens (non-medically same Q: How Premium can Frame my Allowance? frames necessary) to costs, choose up current to from? $ , doctor every plan join year. the The A: network? No, Frames the exceeding frames will the differ plan by allowance location, (Premium but each location You outlined Frames) contact lens fitting fee is also covered, at 100% in-network, A: will may have in refer the a Ford your wide Vision doctor variety Plan to of us styles are for charged to inclusion choose by in from. the our prounder the benefit every plan year. Out-of-network benefits network. vider based Request on the following that your formulary: for contact lenses provide for a doctor reimbursement contact of our up to Q: How Director can of Provider my current Relations doctor at join the $50.00 every plan year. Contact lens fitting fees are not network? ext. covered 1506 under for the an out-of-network application benefit. packet, or Q: A: Do You all may optical corporate@heritagevisionplans.com refer your locations doctor to us have for inclusion the same in our Q: Can frames network. I get to Request both choose contact that from? your lenses doctor and glasses? contact our A: Q: Can You No, Director are the I get frames eligible of both Provider will contact to differ receive Relations by lenses contact location, and lenses but glasses? each OR glasses location ext. are same will 1506 eligible have Plan for a Year wide to an receive variety as application a covered contact of styles lenses benefit. to packet, choose OR glass- from. or in A: You the es in the same corporate@heritagevisionplans.com Plan Year as a covered benefit. Q: How What are can medically my current necessary doctor contact join lenses? the A: Q: network? Can Is Lasik I get a both covered contact or partially lenses covered and glasses? benefit? Medically necessary contacts are prescribed to correct the A: Ford You better are may Motor eye eligible refer to Company 20/70 your to receive due doctor members to: contact to us for receive lenses inclusion a OR 15% in glasses network. count in the on same Lasik Surgery Plan Year at as designated a covered benefit. locations our dis- 1) cataract Request surgery that your doctor contact our Director only. 2) extreme The of locations Provider visual acuity Relations can problems be at found not correctable on our with Q: ext. Is Lasik 1506 spectacle a covered for lenses an or application partially covered packet, benefit? or A: Ford Motor Company members receive a 15% discount How 4) keratoconus on do Lasik I know Surgery which at of designated the toll-free locations web 3) significant site: corporate@heritagevisionplans.com anisometropia Q: Q: Can Prior only. numbers I approval get The both listed locations required contact in this can to lenses book be be eligible to and found use? glasses? for on the our medically A: You necessary If you are need eligible contact information to lenses receive benefit. contact regarding lenses eligibility OR glasses provider web or in the site: same locations, Plan Year use the as a covered benefit. toll Q: free How number. do I know This will which connect of the you toll-free the Customer Q: Is Lasik a covered or partially covered benefit? Service numbers Center listed or in IVR this system. book to use? A: Ford Motor Company members receive a 15% discount on Lasik Surgery at designated locations A: If you need information regarding eligibility or provider For all other locations, member use service the needs, please use the toll only. The locations can be found on our free number. This toll will free connect number. you This to the will Customer connect Service you to the Center Heritage or IVR Vision system. Plans administrative offices web site: Q: How do I know which of the toll-free For all other member service needs, please use the numbers listed in this book to use? toll free number. This will connect A: If you need information regarding eligibility or you to the Heritage Vision Plans administrative offices provider locations, use the toll free number. This will connect you to the Customer Service Center or IVR system. Heritage Vision Optical Plans For all other member service needs, please use the 10 59

12 Glossary of Eyewear Terms The The Eyewear Eyewear Terms Terms in in this this Glossary Glossary are are provided provided for for informational informational purposes purposes only. only. They They are are not not meant meant to to reflect reflect actual actual covered covered benefits benefits under under your your vision vision plan. plan. Please Please refer refer to your to page covered 3, of benefits this Handbook, starting for on your page covered 3 of this benefits. Handbook. DIFFERENT TYPES OF PRESCRIPTION LENSES Based upon the particular eyesight disorder, different types of corrective lenses are prescribed. As a rule, there are 4 types of prescription lenses: Single Vision, Bifocal, Trifocal, and Progressive. Single Vision Lenses Single Vision lenses have only one viewing area throughout the lens. This corrected area can be for far distance, near distance, or reading. Bifocal Lenses Bifocals (meaning a lens with two points of focus, usually one for far distance and one for near distance) are some of the most commonly prescribed multi-focal lenses. A small portion of the bifocal eyeglass lens is reserved for the near-vision correction. The rest of the lens is usually a distance correction, but may have no correction at all if the wearer has good distance vision. Trifocal Lenses Trifocal lenses are lenses with three points of focus: usually for distance, intermediate and near. Trifocals have an added segment above the bifocal for viewing things in the intermediate zone: about an arm's length away. Computer terminals are typically in the intermediate zone. Progressive Lenses Progressive lenses correct vision for multiple distances without the visible segment lines seen in bifocal or trifocal lenses. Instead they have a graduated section in which the power of the lens progresses smoothly from one prescription to the other, allowing the wearer to see clearly at all distances. Heritage Vision Plans 28 Heritage Vision Plans 118

13 Glossary of Eyewear Terms (continued) EYEGLASS LENS MATERIALS Choosing the right lens material for your eyeglasses is an important decision, and there are several options. Plastic Lenses Plastic remains the most popular lens material for eyeglasses in the United States, accounting for nearly 50% of all lenses sold. Plastic is generally regarded as the economy choice in lenses. It offers good optical clarity at a lower price point. Due to thickness, it is not typically recommended for higher prescription powers. Polycarbonate Lenses Polycarbonate Lenses are the most durable of all lenses. These lenses are over ten times more impact resistant than regular plastic. They are also one of the lightest, thinnest lens materials used in eyewear (up to 40% thinner and 30% lighter than standard plastic lenses). Polycarbonate remains a good choice if you want the safest and/or lightest lenses possible. It is also an excellent material choice for children. Hi Index Lenses Hi Index lenses are an excellent alternative for patients with higher prescriptions that want the thinnest, most attractive lenses possible. Hi Index lenses range from 20% to 65% thinner than plastic lenses (depending on the refractive index). The higher the refractive index, the thinner the lens (and typically the higher the cost). Trivex Lenses The Trivex lens is a lightweight, impact resistant material much like polycarbonate. It offers the added benefits of lower visual distortion, better optics, and inherent U.V. Protection. Trivex is a great substitute for polycarbonate lenses in prescription sunglasses because Trivex can be easily tinted, whereas polycarbonate cannot. Heritage Vision Plans 12

14 Glossary of Eyewear Terms Glossary of Eyewear (continued) Terms EYEGLASS LENS COATINGS AND OPTIONS There are many different choices in eyeglass lens coatings and other optical options. These coatings and options can enhance the performance and appearance of your eyeglass lenses. Scratch Resistant Coating The material in plastic lenses is relatively soft and is easily scratched if it is not coated with scratch-resistant coating. This coating, a much harder plastic compound, is applied to the lens surface. The " Scratch Coat " greatly increases the lens' resistance to scratches and abrasions, however it too can be scratched. Anti-Reflective or AR Coating Anti-Reflective Coatings help reduce the reflection on the lenses. When driving (day or night), or using the computer, they reduce the glare and lessen strain on the eyes. What you see is both clearer and sharper. AR Coating also cosmetically enhances the lens, making the lens almost invisible. Your eyes, not the glasses, become the focus of attention. Ultra-Violet or UV Coating UV Coating helps protect the eyes from the harmful damage caused by the sun. This protection helps the eyes tolerate bright sunlight and softens harsh light without making the glasses seem darker. (Note: Both Polycarbonate and Trivex lenses have builtin Ultra-Violet protective properties.) Photochromic or Transitions Lenses Photochromic lenses change from light to dark through changing levels of sunlight. " Transitions " is the most well-known brand in the category of Photochromic lenses. When worn indoors they are virtually clear. When worn outside they change to a dark color. Polarized Lenses Polarized Lenses block out virtually all Ultra-Violet Rays. These lenses help to eliminate haze and glare, while increasing visibility. Heritage Vision Plans 13

15 Member Rights and Responsibilities/ Privacy Practices If you would like to request a copy of our Member Rights and/or Notice of Privacy Practices, please contact us at: Plan Administrator Heritage Vision Plans, Inc. One Woodward Avenue, Suite 2020 Detroit, MI Phone: (888) Fax: (313) corporate@heritagevisionplans.com Member Rights and Responsibilties Members may be required to cooperate in the subrogation and coordination of benefits. Benefits may not be assigned. Members shall notify their employer in case of address change. Members shall have the right to inspect and review their own medical records Provider Information Information about any participating provider is available from Heritage Vision Plans at the above listed address. Non-Discrimination Heritage Vision Plans does not discriminate on the basis of race, color, creed, national origin, residence within the approved service area, lawful occupation, sex, handicap, or marital status. Heritage Vision OpticalPlans 14

16 Corporate Office One Woodward Avenue, Ste Detroit, MI