Vision Benefit Summary

Transcription

1 Hobart and William Smith Colleges Group Number: Vision Benefit Summary About Your Benefits: Eye care is a vital component of a healthy lifestyle. With vision insurance, having regular exams and purchasing contacts or glasses is simple and affordable. The coverage is inexpensive, yet the benefits can be significant! Guardian provides rich, flexible plans that allowyoutosafeguardyourhealthwhilesavingyoumoney.reviewyourplanoptionsandseewhyvisioninsurancemaybeagreat benefit for you. Significant out-of-pocket savings available with your Full Feature plan by visiting one of Davis Vision's network locations including retailcenterssuchaswal-mart,jcpenney,sears,target,sam sclub,andpearle. Your Vision Plan Your Network is Copay Exams Copay $ 10 Materials Copay(waived for non-formulary elective contact lenses) $ 25 Sample of Covered Services Full Feature- Designer Davis Vision In-network You pay(after copay if applicable): Out-of-network Eye Exams $0 Amount over $50 Single Vision Lenses $0 Amount over $48 Lined Bifocal Lenses $0 Amount over $67 Lined Trifocal Lenses $0 Amount over $86 Lenticular Lenses $0 Amount over $126 Frames 80% of amount over $130* Amount over $48 Contact Lenses(Elective and conventional) 85% of amount over $130* Amount over $105 Contact Lenses(Planned replacement and disposable) 85% of amount over $130* Amount over $105 Contact Lenses(Medically Necessary) $0 Amount over $210 Cosmetic Extras Avg % off retail price No discounts Glasses(Additional pair of frames and lenses) Courtesy discount from most providers Laser Correction Surgery Discount Up to 25% off the usual charge or 5% off promotional price Service Frequencies Exams Lenses(for glasses or contact lenses) Frames Every calendar year Every calendar year Every calendar year No discounts No discounts Network discounts(cosmetic extras, glasses and contact lenses.) Applies to first purchase& courtesy discount from most providers on subsequent purchases. Dependent Age Limits (Non-Student/ Student) Benefit includes coverage for glasses or contact lenses, not both. 20/26 This is only a partial list of vision services. Your certificate of benefits will show exactly what is covered and excluded. Hobart and William Smith Colleges Benefit Summary The Guardian Life Insurance Company of America, 7 Hanover Square, New York, NY

2 With the Davis Vision Designer plans, frames from the Fashion or Designer collections are covered in full in excess of the plan s materials copay, if applicable. Frames from the Premiercollectionarecoveredinfullinexcessofa$25copayappliedinadditiontotheplan smaterialscopay,ifapplicable. Framesfromanetworkproviderthatarenotinthe collections are covered up to the plan s retail allowance in excess of the plan s materials copay, if applicable. Contact lenses from Davis Vision's Collection are available at most private practice locations with Full Feature and Materials Only plans. Contacts from the collection are covered in full including fitting and evaluation, in excess of the plan's materials copay. Elective contacts that are not part of the Collection are covered up to the plan's elective contact lens allowance and the materials copay is waived. For Davis Vision, complete eyeglasses must be purchased at one time from one provider. For example, if a member purchases only lenses, he or she cannot purchase frames later in the same benefit period. The member is not eligible for new vision materials until the next benefit period. Only charges for an initial purchase can be used toward the material allowance. Any unused balance remaining after the initial purchase cannot be banked for future use. *Due to lower prices available at Wal-mart and Sam's Club locations, discounts do not apply. Members will pay 100% of the amount over their allowance. Manage Your Benefits: Go to to access secure information about your Guardian benefits including access to animageofyouridcard.youron-lineaccountwillbesetup within 30 days after your plan effective date. Find A Vision Provider Need Assistance? Call the Guardian Helpline(888) , weekdays, 8:00 AM to8:30pm,est.refertoyourmemberid(socialsecurity number) and your plan number: PleasecalltheGuardianHelplineifyouneedtouse your benefits within 30 days of plan effective date. Visit Clickon FindAProvider ;Youwillneedtoknowyourplan andvisionnetwork,whichcanbefoundonthefirstpageof your vision benefit summary. EXCLUSIONS AND LIMITATIONS Important Information: This policy provides vision care limited benefits health insurance only. It does not provide basic hospital, basic medical or major medical insurance as defined by the New York State Insurance Department. Coverage is limited to those charges that are necessary for a routine vision examination. Co-pays apply. The plan does not pay for: orthoptics or vision training and any associated supplemental testing; medical or surgical treatment of the eye; and eye examination or corrective eyewear required by an employer as a condition of employment; replacement of lenses and frames thatarefurnishedunderthisplan,whicharelostorbroken(exceptatnormal intervals when services are otherwise available or a warranty exists). The plan limits benefits for blended lenses, oversized lenses, photochromic lenses, tinted lenses, progressive multifocal lenses, coated or laminated lenses, a frame that exceeds plan allowance, cosmetic lenses; U-V protected lenses and optional cosmetic processes. The services, exclusions and limitations listed above do not constitute a contract andareasummaryonly.theguardianplandocumentsarethefinalarbiterof coverage. Contract#GP-1-DAVIS-05-VIS et al. Laser Correction Surgery: Upto25%offforvisionlasersurgery. Laser surgery is not an insured benefit. The surgery is available at a discounted fee. The covered person must pay the entire discounted fee. In addition, the laser surgery discount may not be available in all states. Hobart and William Smith Colleges Benefit Summary The Guardian Life Insurance Company of America, 7 Hanover Square, New York, NY

3 Value Added Features One-Year Breakage Warranty All plan eyeglasses at national retailers come with a breakage warranty for repair or replacement of the frame and/or lenses for a period of one year from the date of delivery. At private practice providers, the warranty would cover all lenses and frames from the Davis Vision Collection only. A benchmark mail-order contact lens replacement program endorsed by lens manufacturers After your plan materials benefit has been used, purchase replacement contact lenses with significant savings at: Conducts pricing review to ensure lowest prices guaranteed Simple price match guarantee. Members jus call LENS123 will ship replacement contact lenses or solution anywhere the same day Nationwide credentialed network of renowned ophthalmologists and eye surgeons at pre-eminent Eye Care Centers of Excellence Up to 25% off the provider s Usual and Customary;* or 5% off promotional price (whichever is lower) o Usual and Customary Fees: $1000-$2400 per eye o Davis Vision Typical Pricing: $895-$1800 per eye * Some centers provide a flat fee equating to these discount levels 9

4 Contact Lens Collection The Davis Vision Contact Lens Collection is available in most participating independent provider offices but not in retail locations. At retail locations your plan-specified Allowance for Contact Lenses will be applied. The Collection benefit is offered exclusively with full-feature and materials-only plan designs.* Contact lens evaluation and fittings are included at no additional charge when Collection contacts are prescribed. Contact lenses not included in the Collection are covered up to the plan s elective contact lens allowance and the copay is waived. In addition, when the evaluation, fit, and lenses are supplied by the same vision provider at the same time, all costs can be applied to the allowance. TYPE LENS MANUFACTURER Planned Replacement Includes two boxes (Each box of lenses can last up to one year depending on the provider-recommended wearing schedule) Purevision Proclear Compatibles Frequency 55 Bausch & Lomb Disposable Includes four boxes Soflens 38 (6 pack) Focus Dailies (30 pack) Biomedics XC Biomedics 38/Ultraflex 38 Biomedics 55 Clear Site (1-Day 30 pack) Acuvue Acuvue 2 Acuvue Advance Plus 1-Day Acuvue (30 Pack) Bausch & Lomb CIBA Vision *Available at most participating independent provider offices. All contacts in our Collection are Single-Vision Spherical lenses. Collection is subject to change. A basic copayment may apply. 11

5 Members Save on Eyewear Enhancements through Davis Network Discounts Designer Plan Spectacle Lenses Member Cost All ranges of prescriptions (single vision, bifocal, trifocal) Choice of glass or plastic lenses Oversize lenses Fashion or gradient tinting of plastic lenses Blended Segment Lenses $20 Coating - Scratch Resistant $20 Coating - Ultraviolet $12 Corning Photochromic Glass Lenses $20 Intermediate Vision Lenses $30 Polycarbonate Lenses $30* Progressive Lenses - Standard $50 Progressive Lenses (VarilexTM, etc.) - Premium $90 Coating Ultra Anti-Reflective $60 Coating - Premium Anti-Reflective $48 Coating - Standard Anti-Reflective $35 Hi-Index Lenses $55 Plastic Photosensitive Lenses $65 Polarized Lenses $75 Eyeglass Breakage Warranty Prices subject to change For standard eyeglass lenses, you will receive the lower of the Davis vision discounted charge or Walmart or Sam s Club everyday low price. *Polycarbonate lenses covered-in-full for monocular patients and patients with prescriptions 6.00 diopters or greater. or contact member services at for more information 13

6 It s easy to use your vision benefits. You don t even need an ID card! Your Guardian vision benefits are designed to save you money on important treatments to keep you healthy, by making it easy for you to find a network provider in your area. The best way to save money is to see a provider in your network. It s easy to find a network eye care provider: Visit and click on Find a Provider. Under Vision, select Davis Vision as your network Follow the easy steps to search. You can also find an eye care provider on the go from your smart phone simply download our app at You ll need your Member ID number or your Social Security Number for your first visit with the provider. The Member ID number is included in your enrollment material and available from your employer.* Once your plan is activated, you can also view and print an image of your ID card from or through our smart phone app. Use your Member ID number to register. *Your ID Number is located on the front of your enrollment materials and on the top right corner of the enrollment form