Vision Insurance. For Your Employees and Their Families. GH S11478 (exp )

Transcription

1 Vision Insurance For Your Employees and Their Families S11478 (exp ) GH-1157

2 Insurance Overview SIHO believes that valuable employee benefits such as vision care should not be limited to just larger employers. This is why we offer SIHO Vision for our smaller employer group customers. SIHO Vision makes it easy to provide coverage: Insurance plan coverage is offered on a voluntary basis with no cost to the employer. If an employer chooses to help pay for the cost of coverage, premium rates will be even lower! The participation minimum is only two employees and is determined at the time of initial enrollment. Participants can receive the maximum benefit from using one of the many participating eyecare professionals. Out -of-network coverage is also provided. Employers and employees need to complete only one application for both SIHO Health and SIHO Vision coverage. SIHO will send just one bill to the employer for both health plan and vision coverage. Participation in the SIHO Health Plan is not required. General Information SIHO Vision is provided through a partnership with Security Life Insurance Company. Due to the relationship with Security Life, employers do not have to worry about separate eligibility, coverage, or premium payment rules for the vision coverage. The requirements for SIHO Vision are the same as SIHO Health coverage. Premiums, Renewability Applicable Premium Rates are guaranteed for each Participating Employer Unit for 24 months from date of issue. Thereafter, rates are subject to change in accordance with the Master Policy. Coverage is renewable as long as eligibility criteria are satisfied and premiums are paid when due. SIHO Dental Discount If the employer group offers SIHO Vision with SIHO Dental and participation requirements are met for both, the premium rates for both products will be reduced by 5%. SIHO Vision provides a choice of two different plan design options. The 12/12 Plan covers eye exams and corrective lenses every 12 months, the 12/24 plan covers eye exams every 12 months and corrective lenses every 24 months. 2

3 Insurance Designs SIHO Vision uses the EyeMed Access network which includes such familiar names as Lenscrafters, Pearle Vision, Sears Optical, Target Optical, along with thousands of independent eye care professionals. 12/12 Plan 12/24 Plan Eye Examination (Plan ) (Plan ) Frequency Once every 12 months Once every 12 months Co-pay $10 $10 Eyeglass Lenses Frequency Once every 12 months Once every 24 months Co-pay $20 $20 Frames Frequency Once every 12 months Once every 24 months Co-pay $0 $0 Contact Lenses Frequency Same as glasses Same as glasses Co-pay Same as glasses Same as glasses What the benefits include Eye Examination: A routine, complete eye examination, refraction and prescription for eyeglasses. Contact lens examinations require additional fees. If indicated, your doctor may recommend additional procedures which are the responsibility of the member. Eyeglass Lenses: Standard uncoated plastic lenses of any size or strength. Frames: Any frame up to a regular retail value of $100. Frames above $100 retail are available at an additional charge. Contact Lenses: Any pair of contact lenses up to a regular retail price of $100, obtained from a network provider or the mail order program. Contacts above $100 are available at an additional charge. 3

4 Insurance Designs (Cont.) Out of Network Benefits: The greatest benefit is realized when network providers are used (see directory on pages 5-7) but members may choose non-network providers, paying the provider and receiving reimbursement from the plan according to the schedule below. Call the toll-free number for a claim form. 12/12 Plan 12/24 Plan Eye Examination (Plan ) (Plan ) Up to $25 $25 Frames Up to $40 $40 Eyeglass Lenses - single vision Up to $20 $20 Eyeglass Lenses - bifocal Up to $30 $30 Eyeglass Lenses - trifocal Up to $40 $40 Contact Lenses Up to $60 $60 LASIK - Non-insured Discount Benefit: The EyeMed Access network provides discounts to insured individuals interested in LASIK the laser vision correction procedure. This NON- INSURED benefit is offered at a savings of 15% off the regular retail price or 5% off the promotional price when using the network. For information or to locate a participating doctor, call Additional Benefits Lens Options (add to lens pricing listed above) Option Insured Co-payment UV Coating $15 Tint $15 Scratch Resistance $15 Polycarbonate $40 Anti-Reflective $45 Standard Progressive $65 Other add ons 20% Retail Discount 4

5 Provider Directory SIHO Vision uses the EyeMed Access vision network. The following is a partial listing of participating providers in our insured service area. Provider participation changes constantly; for the most current directory please visit EyeMed on the internet at or call Bloomington Area 2812 E THIRD ST BLOOMINGTON, IN (812) DR. JEAN-PAUL ETIENNE OD PEARLE VISION COLLEGE MALL 3024 E THIRD STREET #LOSC (812) DR. RUTHANN R BERCK OD LENSCRAFTERS COLLEGE MALL 2852 E THIRD ST (812) DR KRISTINA MORRIS LLC 3510 W STATE RD 46 BLOOMINGTON, IN (812) DR. LLOYD K DEWAR OD HOOSIER FAMILY EYECARE 121 S 3 RD ST ELLETSVILLE, IN (812) COMMUNITY EYE CARE CENTER 803 N MONROE ST BLOOMINGTON, IN (812) LANDMARK EYECARE 355 S LANDMARK AVE BLOOMINGTON, IN (812) BLOOMINGTON OPTOMETRY 606 S COLLEGE AVE BLOOMINGTON, IN (812) DR. KHASHAYAR TONEKABONI OD ATWARER EYE CARE CENTER 800 E ATWATER AVE STE 316 BLOOMINGTON, IN (812) DR. TAVEL S ONE HOUR OPTICAL 2552 E THIRD ST (812) INSIGHTS OPTICAL INC 415 CLARIZZ BLVD (812) HOOSIER EYE DOCTOR 1105 S COLLEGE MALL RD (812) DR. TRAVIS DOTTERER OD 40 E MORGAN ST SPENCER, IN (812) Columbus Area DR VANA H. EVANS OD 222 COMMONS MALL COLUMBUS, IN (812) COERS FAMILY EYECARE PC 2520 CALIFORNIA ST STE G COLUMBUS, IN (812) MAX A. HENRY MD 1930 DOCTORS PARK DR COLUMBUS, IN (812) VISION VALUES BY DR. TAVEL 2440 N NATIONAL RD COLUMBUS, IN (812) DOUGLAS R. WILSON MD TH ST COLUMBUS, IN (812) ROBERT D. WOODRUFF OD INC FOLXPOINTE DR COLUMBUS, IN (812) EXPERT EYECARE EDINBURGH 210 W MAIN CROSS EDINBURGH, IN (812) (continued on next page)

6 Provider Directory (Cont.) Columbus Area (cont.) MERLE K PICKEL, JR OD 50 E WILLOW ST STE A NASHVILLE, IN (812) DR ABIGAIL S. DAVID OD TARGET OPTICAL 895 S STATE RD GREENWOOD, IN (317) DR DAVID E. ANDREWS OD 1251 US HWY 31 NORTH GREENWOOD, IN (317) JC PENNEY OPTICAL 1251 US HIGHWAY 31 NORTH GREENWOOD, IN (317) Evansville Area JC PENNEY OPTICAL 800 N GREEN RIVER RD (812) DR DONALD A. HALL OD LENSCRAFTERS 800 N GREEN RIVER RD (812) S GREEN RIVER RD (812) VISION SERVICE CORP 4810 TECUMSEH AVE (812) RIDGWAY EYECARE CENTER PC 562 S GREEN RIVER RD (812) DION J DULAY MD FACS PC 5200 WASHINGTON AVE EVANSVILLE, IN (812) THE EYE GROUP OF SOUTHERN INDIANA 1449 KIMBER LANE STE 102A (812) ROSE OPTICAL ONE EVANSVILLE 1484 N GREEN RIVER RD (812) DR STEVEN F. SAMPSON 4404 WASHINGTON AVENUE EVANSVILLE, IN (812) EYE-MART 6614 LOGAN DR (812) TILLMAN EYECARE EAST 1700 SOUTH GREEN RIVER RD (812) DR SCOTT R BRIZIUS OD DR STACEY O EMBRY OD CHARLES A BRIZIUS OD INC LINCOLN AVE EVANSVILLE, IN (812) OHIO VALLEY INSTITUTE 1001 WALNUT ST EVANSVILLE, IN (812) Jasper Area GRAMELSPACHER OPTOMETRY CLINIC 115 E 9 TH ST JASPER, IN (812) RICK D BAUER OD 109 W MAIN PO BOX 296 LOOGOOTEE, IN (812) WABASH VALLEY EYE CENTER LLC 715 S 9 TH ST PETERSBURG, IN (812) DR RAMSEYS VISION CENTER 102 S 2 ND ST PETERSBURG, IN (812) EDWARD F UYESUGI 567 S MAPLE ST FRENCH LICK, IN (812)

7 Provider Directory (Cont.) WABASH VALLEY EYE CENTER LLC 1209 S ST RD 57 WASHINGTON, IN (812) VALLEY OPTICAL II, INC 400 E NATIONAL HWY WASHINGTON, IN (812) INSIGHTS OPTICAL INC 8849 HWY 56 W FRENCH LICK, IN (812) RICHARD E HALE OD 106 E MAIN ST WASHINGTON, IN (812) Logansport Area 3900 E MARKET ST (574) EYE PHYSICIANS INC 120 MICHIGAN AVE STE 240 DIANNE J BROWN OD 412 NORTH ST (574) KENNETH E LAWRENCE OD 216 E MARKET ST (574) GREGORY S DENSBORN OD 824 E BROADWAY (574) LOGANSPORT EYE CARE ASSOC. 326 BURLINGTON AVE PO BOX 597 (574) FAWCETT OPTOMETRY AND VISION 2500 GEORGE ST. (574) DRS PRICE AND SHEPLER 444 MALL RD (574) Seymour Area DR THOMAS E. SMITH OD CONNER SMITH EYE CENTER 707 W TIPTON ST SEYMOUR, IN (812) DRS DOWNING AND ROBERTS 321 N WALNUT ST SEYMOUR, IN (812) DR LINDA FISCHER AND ASSOCIATES INC 1125 MEDICAL PL SEYMOUR, IN (812) MAX A. HENRY MD 301 HENRY ST STE 200 (812) EXPERT EYECARE PC 401 HENRY ST (812) LISLE FAMILY EYE CARE 747 N STATE ST (812) DR KIRK A. HEARNE OD DR WILLIAM D. BURNETT OD BURNETT, MONTGOMERY AND HEARNE 401 HENRY ST (812) DUTY OPTICAL 502 HOOSIER STREET (812) HWY 131 JEFFERSONVILLE, IN (812) E LEWIS AND CLARK PKWY CLARKSVILLE, IN (812) DR POLLY E. HENDRICKS OD DR JOHN G. MESTEL OD LENSCRAFTERS 757 E LEWIS AND CLARK PKW STE 234 CLARKSVILLE, IN (812)

8 Vision Expenses Not Covered Limitations - In no event will payment exceed the lesser of: 1. the actual cost of covered Services or Materials; or 2. the limits of the Policy, shown in this Schedule. Exclusions - We will not cover: 1. Orthoptic or vision training and any associated supplemental testing. 2. Plano lenses. 3. Lens Coatings 4. Two pair of glasses, in lieu of bifocals or trifocals. 5. Medical or surgical treatment of the eyes. 6. Any eye examination, or any corrective eyewear, required by an employer as a condition of employment. 7. Any injury or illness when covered under any Workers' Compensation or similar law, or which is work-related. 8. Customization of bifocal lenses to a progressive or no-line lens 9. Photo-chromatic lenses 10. Sub-normal vision aids or non-prescription lenses. 11. Services rendered or Materials purchased outside the U.S. or Canada, unless: a) the Insured resides in the U.S. or Canada; and b) the charges are incurred while on a business or pleasure trip. 12. Charges in excess of the Usual and Customary charge for the Service or Materials. 13. Charges incurred after: a) the Policy ends; or b) the Insured's coverage under the Policy ends, except as stated in the Policy. 14. Experimental or non-conventional treatment or device. 15. Spectacle lens treatments or "add-ons", except solid tints (#1 & #2), and oversize lenses. 16. High Index lenses of any material type. 17. Lost or broken Materials, except when replaced at normal intervals when Services are available. This brochure provides a very brief description of some of the important features of your plan and is subject to individual state regulations. It is not the Insurance contract nor does it represent the Contract. A full explanation of benefits, exceptions and limitations is contained in the Certificate of Insurance under Group Vision Policy Form GH Premium rates may change upon renewal. This policy is renewable at the option of the Company. 8 AC0812