what s new online... www.mycompbenefits.com Explore the exciting new features that make it easier for you to find information and make changes to your CompBenefits vision plan. Change Personal Information: You can now access and change personal demographic information, such as your name and address, directly from your CompBenefits account. Search for a Provider: By registering at MyCompBenefits.com, you can easily search for a Provider in your area that accepts your specific plan. ID Card: You may print temporary ID Cards and request permanent ID Cards online. Check the Status of a Claim: It s easy to check your claim status. Simply select the family member who received services and enter the time period to obtain a list of claims. From the list, click on the View option to see details on how the claim was paid. Ask Questions about a Claim: We re here to answer any questions you may have. From the claims detail screen, click Claims Question. You ll receive a response within one business day. How to Register Online: It s fast and simple! Step #1: Go to www.mycompbenefits.com. Step #2: Select Click here to Register Now! Step #3: Type the requested information on the PIN Registration page and click Next. Step #4: In the next page, enter your Member ID number. Step #5: Enter your demographic information as it appears on your enrollment form or as indicated on your ID card. Click Submit. Member Access to Online Services 24 Hours a Day, 7 Days a Week
visioncare plan What to expect from your vision plan: Your eyesight is nothing to take for granted. It s how we see a loved one s face clearly or a beautiful sunset. But your sight can begin to deteriorate over a long period of time without your knowing there is a problem. As with any other important asset like your home or car wouldn t you feel more at ease if you knew your routine eye care was covered by a company with decades experience helping people like you? With CompBenefits VisionCare Plan, you can take advantage of coverage you need for eye examinations and eyeglasses or contacts. See the Difference You can also choose to take advantage of VisionCare Plan s deep discount for LASIK surgery. And you won t have to hunt hard to find a doctor close to your home or work. The VisionCare Plan network includes some 20,000 ophthalmologist and optometrist locations one third of all private practitioners in the country. Yet, it doesn t mean you can t see an out-of-network doctor because VisionCare Plan offers benefits in-network or out-of-network. It s your choice. You ll find what you need @ www.mycompbenefits.com CompBenefits has made understanding and accessing your VisionCare Plan benefits simple. Just take a few moments to register at www.mycompbenefits.com, and you ll have access to our VisionPass, which is necessary to take with you to your eye doctor appointment. Plus, you ll see all of your benefits on screen, including the frequency of your benefits, frame and lens as well as contact lens allowances. You ll have access to our database of 20,000 eye doctor locations through our Provider Locator. SSVCP
Jacksonville University Open your eyes to high-quality vision care! The average family spends close to $600 each year on routine eye health care. Using CompBenefits VisionCare Plan, you will receive your routine eye health care with just a small copayment. CompBenefits VisionCare Plan provides benefits for covered: Eye health examinations Frames Eyeglass Lenses Contact Lenses Plus you will receive: LASIK surgery discount Preferred member pricing for other frame and lens options* When ordering from one of our network eye doctors, you will also receive in the year of your eye exam: A 20% discount on a second pair of eyeglasses A 15% discount on your contact lens fitting fee MONTHLY RATES SERVICE FREQUENCY COPAYMENTS Employee only: $ 6.50 Vision exam: Once every 12 months Exam: $10 Employee + family: $18.60 Lenses: Once every 12 months Materials: $25 Frame: Once every 24 months SAVINGS! SEE THE DIFFERENCE You can save money two ways with VisionCare. First, the cost of plan services and materials is discounted and prepaid. So except for any co-payments, you have no out-of-pocket expenses for covered services and supplies when you use one of our network doctors. Second, your coverage costs are deducted from your pay before any federal income or FICA taxes are taken out. This makes your taxable wage base lower, so you would pay less tax. Here s an example of how the plan helps you save over the course of a year: If You Get: You Pay: VisionCare Typical Doctor Retail Eye exam.00 $ 85.00 Frame (designer style).00 120.00 Lenses: Bifocal.00 100.00 Option (pink tint #1 or #2).00 15.00 Co-payments: $10 exam/$25 materials $ 35.00.00 Premium ($6.50 monthly x 12) +78.00.00 113.00 $ 320.00 Pre-tax savings (assuming 15% tax bracket & 7.65% FICA) - 17.67 +.00 Total Cost $95.33 $ 320.00 YOUR TOTAL SAVINGS THROUGH VISIONCARE: 70% OFF RETAIL In this example, you would have saved $224.67 in vision care costs with VisionCare Plan. Keep in mind, however, that your actual savings will depend on your plan allowances, your actual premium, the doctors and materials you select, and your own tax situation. * This is not a schedule of maximum benefits. For example, the plan covers frames based on the manufacturer s wholesale price guide. So while the retail price of a covered frame may vary among plan doctors, the value of your covered frame stays the same. Typically, the wholesale frame allowance is equivalent to a retail price of $80-150. You may be required to pay extra only if you choose a frame that exceeds the covered wholesale price.
Maximum Allowances Eye Exam Paid in full Lenses (per pair) Single Paid in full Bifocal Paid in full Trifocal Paid in full Lenticular Contact Lenses Paid in full Elective (fitting, follow-up & lenses) $105* Medically necessary** Paid in full Frame $40 wholesale Lasik*** Members receive benefits when services are received from a TLC Truvision network provider with the following preferred rates: Silver Package: $895/eye for Conventional LASIK Gold Package: $1,295/eye for CustomLASIK Platinum Package: $1,895/eye for CustomLASIK plus Bladeless LASIK (using IntraLase technology). Participating Doctor (After copayments/ Up to plan limits) Members will also receive a 10% discount off UCR charges at other preferred LASIK provider locations, and pay no more than $1,800 per eye for the Conventional LASIK procedure and $2,300 per eye for CustomLASIK. * This allowance is paid with the same frequency as lenses, in place of all other benefits. ** Medically necessary (prior authorization required) is defined as 1) following cataract surgery w/o intraocular lens; 2) correction of extreme visual acuity problems not correctable with glasses; 3) anisometropia greater than 5.00 diopters and asthenopia or diplopia, with spectacles; 4) Keratoconus; or 5) monocular aphakia and/or binocular aphakia where the doctor certifies contact lenses are medically necessary for safety and rehabilitation to a productive life. *** Plan members must first contact CompBenefits for a list of providers and to receive a Refractive Care ID card. This schedule shows only a few of the covered procedures. Please see your Benefit Administrator for a complete schedule. This schedule is intended for comparison purposes only. The benefits of each plan will be determined by the contract. For a complete listing of benefits and exclusions and limitations, please reference your certificate of coverage. Out-of-network benefits apply under the VisionCare Plan, but benefits are higher when a participating doctor is utilized. Limitations and Exclusions apply. HOW DOES VISIONCARE PLAN WORK? You can choose a network provider at www.mycompbenefits.com. Depending on your plan, either you or your doctor will download a VisionPass Form from www.compbenefits.com. You must use the form in the time specified for services*. Visit your doctor, who will provide you with a comprehensive eye exam and order prescribed eyeglasses or contacts, if necessary. Pay any copayments as well as any additional expenses for cosmetic items you have chosen. That s the end of your paperwork. CompBenefits pays the doctor directly for his or her professional services. It s as easy as that! * If you do not use your form in the time specified for services, you won t be able to download another until the next time you are eligible for benefits. However, you can request an extension from our Customer Care team at 800-865-3676. CAN I GET CONTACTS INSTEAD OF LENSES? Yes. If you prefer contacts instead of glasses, your vision exam is covered-in-full with your exam co-payment and VisionCare Plan provides a generous allowance of $105.00 to be applied towards your fitting and follow-up fees as well as materials costs. The Contact Lens allowance in LIEU OF THE LENS / FRAME BENEFIT and is provided with the same frequency as your lens benefit. HOW DO I GET FURTHER QUESTIONS ANSWERED? You may contact CompBenefits Customer Care Department with any questions or concerns at: 1-800-865-3676, Monday Thursday 8am-8pm; and Friday 8am-6pm EST. or locate us on the web at www.mycompbenefits.com.
frequently asked questions Q. What are CompBenefits VisionCare Plans? A. CompBenefits VisionCare Plans are network-based vision plans that emphasize high quality routine eye health care from independent eye care professionals. Services and materials are provided on a pre-paid basis, and the plans pay network doctors directly. VisionCare Plan members can also use non-network doctors if they wish. Q. How does VisionCare Plan work? A. Members simply select any in-network optometrist or ophthalmologist and make their appointments. At the time of the appointment, members pay only their co-payments and for any extra cosmetic options selected. There are no forms to complete or claims to file. Members can also choose an out-of-network provider. In this case, they pay their doctor at the time of the visit and submit receipts to CompBenefits for reimbursement. Benefits are paid according to a reimbursement schedule. Q. Are there any limitations to my vision benefit? A. Yes, there are a few. Oversized lenses, when prescribed, may be covered only when patient s face size indicates they are necessary. Blended and progressive lenses are not normally required for visual welfare and are generally excluded. Elective or cosmetic items such as photochromic lenses, fashion color-coated lenses and sun lenses are not normally covered. Q. Does VisionCare Plan exclude anything? A. Yes, some items and services are excluded. Orthoptics or vision training, subnormal vision aids or plano (non-prescription) lenses Replacement of lost or broken lenses, except at the regularly-scheduled plan intervals Medical or surgical treatment of the eyes Care provided through or required by any government agency or program,including Workers Compensation or similar law Q. What do I need to access my benefits? A. You ll need a CompBenefits VisionPass, which you can download from our Web site, www.mycompbenefits.com. You ll take it to your eye doctor, and he or she will file it for you. Some groups, however, may have a plan in which the eye doctor downloads your VisionPass for you. Check with your benefit administrator for more details on how you should obtain your VisionPass. Q. Can I go online to find out more about my plan or get assistance? A. Yes. You can visit www.mycompbenefits.com to learn about your plan, to check your benefits, to use our Provider Locator, to send us an e-mail and more.
Vision Provider Directory Baker, Clay, Columbia, Dixie, Duval, Hamilton, Lafayette, Nassau, Saint Johns, Suwannee and Union Counties The providers listed in this brochure were participating with the plan at the time of printing. Please check with the doctor of your choice or call our Customer Care department at 1-800-749-5855 when making your appointment to make certain he or she is currently a member doctor. You may also visit our website at www.compbenefits.com for a nationwide listing of providers. You must receive services from one of our participating providers in order to receive full benefits (as outlined in your vision care booklet). If you receive service from a provider who does not participate in the plan, you will receive reimbursement according to the non-panel reimbursement schedule established by your group. BAKER Macclenny Futch, OD, Mary M 31 S 6th St 32063 (904)259-6259 Phillips, OD, Robert L 534 S 5th St 32063 (904)259-6797 CLAY Green Cove Springs Reed, OD, Joanne F 401 Bay St 32043 (904)529-7238 Keystone Heights Minesinger, OD, James H 260 S Lawrence Blvd 32656 (352)473-2600 Middleburg Allen, OD, Margaret A 1545 Branan Field Rd Ste 5 32068 (904)291-5800 Anguas, OD, Edwin N 1545 Branan Field Rd Ste 5 32068 (904)291-5800 Orange Park Abshire, OD, Kyle D Abshire, OD, Kyle D Akel, OD, Edward F 195 Blanding Blvd Ste 3 32073 (904)298-1440 Allen, OD, Margaret A 28 Blanding Blvd 32073 (904)264-5483 Anguas, OD, Edwin N 28 Blanding Blvd 32073 (904)264-5483 Ayer, OD, Mary J 1515 Business Center Dr Ste 4 32003 (904)278-1760 Bowman, OD, Christina B Bowman, OD, Christina B Brown, OD, Nichole Y 4605 US Highway 17 Ste 1 32003 (904)269-8161 Donovan, MD, John P Donovan, MD, John P Downer, MD, Donald M Downer, MD, Donald M Green, OD, David A Green, OD, David A Harris III, MD, Clarence M Harris III, MD, Clarence M Hoffman, OD, James R Hoffman, OD, James R Javier, OD, Melanie C Javier, OD, Melanie C Larson, OD, Karen R Larson, OD, Karen R Pecoraro, MD, Russell A Pecoraro, MD, Russell A Reed, OD, Keven C Reed, OD, Keven C Tamsett-Schmidt, OD, Kendra Ji 1515 Business Center Dr Ste 4 32003 (904)278-1760 Wilcox Jr, MD, John D Wilcox Jr, MD, John D COLUMBIA Lake City Bedoya, MD, Eduardo M 876 SW State Road 247 32025 (386)755-7595 Broome III, OD, Frank A 763 SW Main Blvd Ste 101 32025 (386)752-1722 Broome, OD, Kimberly M 763 SW Main Blvd Ste 101 32025 (386)752-1722 Cole, OD, Reaves C 621 SW Baya Dr Ste 101 32025 (386)754-6616 Foreman, OD, Ronald R 763 SW Main Blvd Ste 101 32025 (386)752-1722 Owens, OD, Julie L 763 SW Main Blvd Ste 101 32025 (386)752-1722 DIXIE Cross City Minesinger, OD, James H 85 NE 351 Hwy 32628 (352)498-5007 DUVAL Atlantic Beach Duperault Jr., OD, Herman M 447 Atlantic Blvd Ste 1 32233 (904)247-0211 Grimshaw, OD, Richard S 447 Atlantic Blvd Ste 1 32233 (904)247-0211 Popp, OD, Mark A 447 Atlantic Blvd Ste 1 32233 (904)247-0211 Jacksonville Akel, OD, Edward F 5205 Normandy Blvd Ste 3 32205 (904)781-7717 Akel, OD, Gary M 953 Lane Ave S 32205 (904)786-4442 Bateh, OD, Norman S 1233 Lane Ave S Ste 15 32205 (904)781-6770 Bateh, OD, Norman S 5162 Norwood Ave 32208 (904)764-2591 Bowman, OD, Samuel T 806 Riverside Ave 32204 (904)356-7101 Brown, OD, Jeffrey D 2255 Dunn Ave Ste 101B 32218 (904)757-1495 Brown, OD, Larry G 2001 College St 32204 (904)355-5555 Brown, OD, Monica 1420 Flagler Ave 32207 (904)425-6060 Brown, OD, Monica 7051 Southpoint Pkwy Ste 300 32216 (904)398-2720 Caperton, OD, Bruce M 1840 Dunn Ave Ste 4 32218 (904)751-4483 Carvell, OD, Melanie J 8102 Blanding Blvd Ste 23 32244 (904)777-3937 Cone, OD, Paul J 961 Cesery Blvd 32211 (904)743-1311 Del Campo, OD, Mary Eliza 9400 Atlantic Blvd Ste 62 32225 (904)721-7700 Derickson, OD, John C 8771 Perimeter Park Ct Ste 101 32216 (904)997-8585 Duss, MD, Charles V 6207 Bennett Rd 32216 (904)731-7500 Favale II, OD, Anthony F 953 Lane Ave S 32205 (904)786-4442 Fulghum, OD, Paul T 4225 Lakeside Dr 32210 (904)387-5704 Gerson, OD, Robert 3737 Blanding Blvd 32210 (904)771-8321 Grimshaw, OD, Richard S 5238-17 Norwood Ave 32208 (904)768-1757 Habashi, OD, Hanaa M 1325 San Marco Blvd Ste 900 32207 (904)346-6506 Habashi, OD, Hanaa M 9560 Crosshill Blvd Ste 106 32222 (904)777-2927 Hanna, OD, Muneer N 1704 Southside Blvd Ste 6 32216 (904)722-2020 Hanna, OD, Muneer N 2292 Mayport Rd Ste 6 32233 (904)246-3550 Horning, OD, James A 4788 Hodges Blvd Unit 205 32224 (904)992-9991 Houser, OD, Frank E 13170 Atlantic Blvd Ste 53 32225 (904)221-6500 Howell Jr., OD, Charles N 2115 University Blvd S Ste 1 32216 (904)725-2300 King, OD, Colleen M 2255 Dunn Ave Ste 101B 32218 (904)757-1495 Lancaster, OD, Charles S 6207 Bennett Rd 32216 (904)731-7500 Lanier Jr., OD, James C 806 Riverside Ave 32204 (904)356-7101 Laramie, OD, Tammy A 6816 Southpoint Pkwy Ste 800 32216 (904)296-1980 Leinwohl, OD, Gayle P 9397 San Jose Blvd Ste 2 32257 (904)730-2299 Liane, OD, Peter D 100 W Bay St 32202 (904)356-9431 July, 2010
Mark, OD, Dorothy E 9397 San Jose Blvd Ste 2 32257 (904)730-2299 Mark, OD, Dorothy E 9400 Atlantic Blvd Ste 62 32225 (904)721-7700 McIntosh, OD, Daniel R 3840 Belfort Rd Ste 105 32216 (904)737-1975 Miles, OD, David E 1403 Dunn Ave Ste 15 32218 (904)696-0883 Miles, OD, William F 1403 Dunn Ave Ste 15 32218 (904)696-0883 Mint, OD, Janet M 4131 Southside Blvd Ste 203 32216 (904)646-9737 Phillips, OD, Robert L 1580 Blanding Blvd 32210 (904)387-0025 Popp, OD, Mark A 5238-17 Norwood Ave 32208 (904)768-1757 Potochick, OD, Anthony 2036 Forbes St 32204 (904)387-4057 Powers, OD, Michael A 3546 Saint Johns Bluff Rd S Unit 203 32224 (904)996-1533 Pullen, OD, Stephen M 11808 San Jose Blvd Ste 1 32223 (904)262-2249 Rauchwarger, OD, Alan I 9397 San Jose Blvd Ste 2 32257 (904)730-2299 Rauchwarger, OD, Alan I 9400 Atlantic Blvd Ste 62 32225 (904)721-7700 Reardon, OD, Patrick L 961 Cesery Blvd 32211 (904)743-9955 Roberts, OD, B W 8102 Blanding Blvd Ste 23 32244 (904)777-3937 Schnauss, MD, Roy H 804 Margaret St 32204 (904)359-2020 Schwartz, OD, Steven H 3 Shircliff Way Ste 122 32204 (904)388-3109 Shearer, OD, Jeffrey D 9978 Old Baymeadows Rd Ste 3 32256 (904)641-3937 Sherrill, OD, Donna D 11808 San Jose Blvd Ste 1 32223 (904)262-2249 Shmunes, MD, Neil T 6207 Bennett Rd 32216 (904)731-7500 Simmons, MD, Richard L 6207 Bennett Rd 32216 (904)731-7500 Spurling, OD, Robert L 9119 Merrill Rd Ste 13 32225 (904)743-6410 Stam, OD, Bryan A 100 W Bay St 32202 (904)356-9431 Wagner, OD, Ellen Rogers 806 Riverside Ave 32204 (904)356-7101 Watts, OD, James W 11808 San Jose Blvd Ste 1 32223 (904)262-2249 Weitzen, OD, Amanda 4131 Southside Blvd Ste 201 32216 (904)997-2018 Weitzen, OD, Jerome 213 N Laura St 32202 (904)353-3163 Williams, OD, Chandra M 12961 N Main St Ste 203 32218 (904)696-2027 Williams, OD, Chandra M 1420 Flagler Ave 32207 (904)425-6060 Williams, OD, Chandra M 7051 Southpoint Pkwy Ste 300 32216 (904)398-2720 Williams, OD, Gary O 5353 Soutel Dr Ste B 32219 (904)766-0660 Wood, OD, Wayne W 806 Riverside Ave 32204 (904)356-7101 Jacksonville Beach Domingo, OD, Patrick J 905 Beach Blvd Ste B 32250 (904)246-4831 Duss, MD, Charles V 3316 3rd St S Ste 103 32250 (904)241-7865 Lancaster, OD, Charles S 3316 3rd St S Ste 103 32250 (904)241-7865 Shmunes, MD, Neil T 3316 3rd St S Ste 103 32250 (904)241-7865 Simmons, MD, Richard L 3316 3rd St S Ste 103 32250 (904)241-7865 Stam, OD, Bryan A 905 Beach Blvd Ste B 32250 (904)246-4831 Tirado, OD, Alejandro M 1524 3rd St N 32250 (904)241-3162 NASSAU Callahan Marks, OD, Linda L 542069 US Highway 1 32011 (904)879-2020 Fernandina Beach Crump, OD, Jay P 1411 S 14th St Ste G 32034 (904)321-1333 SAINT JOHNS Jacksonville Dorado-Foster, OD, Grace 450 State Road 13 Ste 107 32259 (904)287-3678 Fisher, OD, Erika Lee 100 State Road 13 Ste A 32259 (904)287-4567 Fisher, OD, Gerald Hugh 100 State Road 13 Ste A 32259 (904)287-4567 Laramie, OD, Tammy A 1631 Race Track Rd Ste 205 32259 (904)287-2853 Ponte Vedra Beach Bowman, OD, Samuel T 120 A1A N Ste 101 32082 (904)280-9000 Falden, OD, Allison 880 A1A N Ste 13 32082 (904)686-1386 Falden, OD, David 880 A1A N Ste 13 32082 (904)686-1386 Houston, OD, Gilbert 150 Professional Dr Ste 300 32082 (904)285-8448 Lanier Jr., OD, James C 120 A1A N Ste 101 32082 (904)280-9000 Wagner, OD, Ellen Rogers 120 A1A N Ste 101 32082 (904)280-9000 Wolf, OD, Karen S 150 Professional Dr Ste 300 32082 (904)285-8448 Wood, OD, Wayne W 120 A1A N Ste 101 32082 (904)280-9000 Saint Augustine Akel, OD, Edward F 212 State Road 312 32086 (904)824-2021 Horning, OD, James A 1835 US Highway 1 S Ste 121 32084 (904)824-0212 Kapadia, OD, Diane L 161 Hampton Point Dr Ste 3 32092 (904)287-9137 Kapadia, OD, Sharokh N 161 Hampton Point Dr Ste 3 32092 (904)287-9137 Miles, OD, Charles 25 Deltona Blvd Ste 1 32086 (904)797-5760 Miles, OD, David E 25 Deltona Blvd Ste 1 32086 (904)797-5760 Miles, OD, Henry E 25 Deltona Blvd Ste 1 32086 (904)797-5760 Womack Jr, OD, John T 1835 US Highway 1 S Ste 121 32084 (904)824-0212 Saint Johns Akel, OD, Edward F 450 State Road 13 Ste 107 32259 (904)287-3678 St Augustine Miles, OD, William F 25 Deltona Blvd Ste 1 32086 (904)797-5760 SUWANNEE Live Oak Broome III, OD, Frank A 522 Ohio Ave S 32064 (386)362-5055 Owens, OD, Julie L 522 Ohio Ave S 32064 (386)362-5055
LASIK & PRK Opening doors to better vision for thousands of people with affordable LASIK & PRK procedures.* reduced fees The LASIK and PRK procedures are available for plan members who are nearsighted or have astigmatism and wear glasses or contacts.** We have contracted with many of the finest facilities and eye doctors to offer these procedures at substantially reduced fees. Extensive publicity and positive patient experience have created the acceptance and growth of laser vision correction. Network doctors can help plan members understand these new procedures and provide access to our network of LASIK and PRK providers. Members receive substantial reductions when procedures are done by network providers. Members can use Lasik provider network doctors at a cost of no more than $1,800 per eye for Conventional Lasik procedures and $2,300 per eye for custom Lasik. Or they can use designated TLC Vision Centers for the Lasik Advantage program that have the following fixed prices: Conventional Lasik - $895 per eye Custom Lasik - $1,295 per eye Custom Lasik with IntraLase - $1,895 per eye easy access to service During your comprehensive eye health examination, your doctor can determine if you are a candidate for LASIK or PRK. If you qualify, the doctor can also make arrangements for the procedure with one of the centers that participates in this program. Plan members can also go directly to one of the participating providers. Your VisionPass Form or your VCP ID Card verifies your eligibility for LASIK and PRK discounts. In either case, you may obtain a VisionPass Form and list of providers from our website (www.mycompbenefits.com) or by calling our Customer Care Department at 800-865-3676.*** To initiate services in the TLC Vision Advantage Program call 888-358-3937 This discount cannot be combined with any other discount or promotional offer. The Humana/CompBenefits LASIK and PRK Program is not affiliated with any medical or health plan. * Laser-assisted in-situ keratomileusis; photorefractive keratectomy. ** If qualified as a LASIK and PRK candidate by the network doctor *** Program availability and professional fees may vary based on location and regulatory approval. Humana/CompBenefits 1511 N. Westshore Blvd Suite 1000 Tampa, FL 33607 (800) 749-5855 (813) 289-2020 www.compbenefits.com LSK 07/08
Group Name: Jacksonville University Please complete the following information: Benefits Enrollment Form Social Security No. Last Name First Middle Date of Birth Home Address Home Phone Gender City State ZIP Code Business Phone List All Your Eligible Dependents That Are To Be Covered First MI Last Sex Birth Date Spouse: Effective Date: Plan Code: Group Number VS3136 Your E-mail Address Agent Number PLEASE CHECK YOUR CHOICE Vision Plan Monthly Rates Employee Only $6.50 Employee + Family $18.60 I wish to enroll in the plan indicated above as offered through my employer. I understand that this is a minimum one (1) year contract. I hereby authorize my employer to deduct all applicable contribution amounts from my salary or other compensation for the plan year, and for future renewal period(s). I understand that such contribution rate is subject to change on the anniversary date of the plan. I hereby represent that all information furnished by me hereon is true and complete to the best of my knowledge. Signature: X Date: