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FAIRFAX COUNTY PUBLIC SCHOOLS
CAREFIRST BLUECHOICE ADVANTAGE PLAN
Vision Benefits Davis Vision
Davis Vision
2
Q. Who provides vision coverage when enrolling in the CareFirst plan?
A. Comprehensive vision coverage is provided by Davis Vision, a leading national vision company, through CareFirst. Both in and out-of-network benefits are included.
Q. How large is the Davis Vision network?
A. Davis Vision has 50,000 points of access across the country that include private practitioners, retail locations and dispensing labs:
For Eyes Sears Optical Sams Club Pearle Vision J.C. Penney Optical Wal-Mart Vision Centers Visionworks Target Optical Americas Best and many others
Q. How do I determine if my provider is in the Davis Vision network?
A. Go to www.carefirst.com/fcps and click on Find a Doctor or Provider in the Davis Vision Plan in the Member Tools section, or contact Davis Vision at 1-888-343-3462.
2017
http://www.carefirst.com/fcpshttp://www.carefirst.com/findadocvision
Davis Vision
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Q. What are my benefits/copayments under the Davis Vision plan?
A. Benefits include:
Eye exams: $20 copay for a comprehensive eye exam at a participating Davis Vision provider (once per calendar year) Eyeglass frames: Covered once every 2 calendar years
No copay for Fashion or Designer frames from the Davis Vision Frame Collection; $25 copay for Premier frames from the Davis Vision Frame Collection $130 allowance for frames not included in the Davis Vision Frame Collection
You can view the Davis Vision Frame Collection by going to www.carefirst.com/fcps Click on Find a Doctor or Provider in the Davis Vision Plan in the bar labeled Member Tools
Lenses (either eyeglass or contacts): Covered once each calendar year Spectacle lenses: No copay for clear plastic single-vision, lined bifocal, trifocal or lenticular lenses. Contact Lenses: No copay for up to 4 boxes of disposable contact lenses (or 2 boxes of planned replacement contact lenses) if included in the Davis Vision Contact Lens Collection. The Collection Includes CooperVision and Vistakon, in both traditional and silicone hydrogel materials, as well as select torics and multifocal lenses. Your participating eye care provider will have a copy of the latest Davis Vision Contact Lens Collection.
2017
http://www.carefirst.com/fcpshttp://www.carefirst.com/findadocvision
Q. My eye care provider is not in the network. Do I receive benefits?
A. Yes, out-of-network benefits are available, but greater savings are achieved by seeing in-network providers. If an out-of-network provider is selected, you will pay the full cost to the provider and then submit a claim for reimbursement. Go to www.carefirst.com/fcps and click on Davis Vision Benefit Summary for in and out-of-network benefit levels. The out-of-network claim form can also be found on www.carefirst.com/fcps.
Q. Can I request my provider be added to the network?
A. Yes. Contact a member service representative at 1-888-343-3462.
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Davis Vision 2017
http://www.carefirst.com/fcpshttp://www.carefirst.com/fcps
Davis Vision
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Q. I need progressive lenses. Are these covered?
A. Many lens options are available for discounted fees. Go to www.carefirst.com/fcps and click on Davis Vision Benefit Summary for more details.
Q. Is laser vision correction surgery covered?
A. While laser vision correction surgery is not a covered benefit, members are entitled to savings of up to 25% off the providers usual and customary fees, or a 5% discount on any advertised special through our network of physicians and refractive surgery centers (some centers provide a flat fee equating to these discount levels). Refer to the website, www.carefirst.com/fcps for more details.
Q. How frequently can I get an eye exam?
A. You may receive a routine eye exam once per calendar year.
2017
http://www.carefirst.com/fcpshttp://www.carefirst.com/fcps
Davis Vision
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Q. Who do I contact to get more information?
A. Contact Davis Vision at 1-888-343-3462
Monday - Friday: 8 a.m. to 11 p.m. (Eastern Time) Saturday: 9 a.m. to 4 p.m. Sunday: 12 p.m. to 4 p.m. or visit: www.carefirst.com/fcps
Click on Find a Doctor or Provider in the Davis Vision Plan in the Member Tools section, and
Click here for the Davis Vision Benefit Summary
2017
http://www.carefirst.com/fcpshttp://www.carefirst.com/findadocvisionhttp://www.carefirst.com/findadocvisionhttp://www.carefirst.com/findadocvisionwww.carefirst.com/fcps/attachments/davis-vision-benefit-summary-2017.pdf
WWW.CAREFIRST.COM/FCPS
Thank You
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CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., CareFirst BlueChoice, Inc., First Care, Inc. and The Dental Network are independent licensees of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association.
Registered trademark of CareFirst of Maryland, Inc.
Notice of Nondiscrimination and Availability of Language Assistance Services
CareFirst BlueCross BlueShield, CareFirst BlueChoice, Inc. and all of their corporate affiliates (CareFirst) comply with applicable federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability or sex. CareFirst does not exclude people or treat them differently because of race, color, national origin, age, disability or sex. CareFirst:
Provides free aid and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats)
Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages
If you need these services, please call 855-258-6518. If you believe CareFirst has failed to provide these services, or discriminated in another way, on the basis of race, color, national origin, age, disability or sex, you can file a grievance with our CareFirst Civil Rights Coordinator. Civil Rights Coordinator, Corporate Office of Civil Rights Telephone Number 410-528-7820
Mailing Address P.O. Box 8894 Baltimore, Maryland 21224
Fax Number 410-505-2011
Email Address [email protected] You can file a grievance by mail, fax or email. If you need help filing a grievance, our CareFirst Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
mailto:[email protected]://ocrportal.hhs.gov/ocr/portal/lobby.jsfhttp://www.hhs.gov/ocr/office/file/index.html
CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., CareFirst BlueChoice, Inc., First Care, Inc. and The Dental Network are independent licensees of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association.
Registered trademark of CareFirst of Maryland, Inc.
Foreign Language Assistance Attention (English): This notice contains information about your insurance coverage. It may contain key dates
and you may need to take action by certain deadlines. You have the right to get this information and assistance in
your language at no cost. Members should call the phone number on the back of their member identification card.
All others may call 855-258-6518 and wait through the dialogue until prompted to push 0. When an agent
answers, state the language you need and you will be connected to an interpreter.
(Amharic) -
855-258-6518 0
d Yorb (Yoruba) ttlko: kys y n wfn npa i adjtf r. le n wn dt pt o s le n lti
gb gbs n wn j gbdke kan. O ni t lti gba wfn y ti rnlw n d r lf. wn m-gb
gbd pe nmb fn t w lyn kd dnim wn. wn mrn le pe 855-258-6518 k o s dr npas jrr
tt a fi s fn lti t 0. Ngbt aoj kan b dhn, s d t o f a s so p m gbuf kan.
Ting Vit (Vietnamese) Ch : Thng bo ny cha thng tin v phm vi bo him ca qu v. Thng bo c th
cha nhng ngy quan trng v qu v cn hnh ng trc mt s thi hn nht nh. Qu v c quyn nhn
c thng tin ny v h tr bng ngn ng ca qu v hon ton min ph. Cc thnh vin nn gi s in thoi
mt sau ca th nhn dng. Tt c nhng ngi khc c th gi s 855-258-6518 v ch ht cuc i thoi cho
n khi c nhc nhn phm 0. Khi mt tng i vin tr li, hy nu r ngn ng qu v cn v qu v s c
kt ni vi mt thng dch vin.
Tagalog (Tagalog) Atensyon: Ang abisong ito ay naglalaman ng impormasyon tungkol sa nasasaklawan ng iyong
insurance. Maaari itong maglaman ng mga pinakamahalagang petsa at maaaring kailangan mong gumawa ng
aksyon ayon sa ilang deadline. May karapatan ka na makuha ang impormasyong ito at tulong sa iyong sariling
wika nang walang gastos. Dapat tawagan ng mga Miyembro ang numero ng telepono na nasa likuran ng kanilang
identification card. Ang lahat ng iba ay maaaring tumawag sa 855-258-6518 at maghintay hanggang sa dulo ng
diyalogo hanggang sa diktahan na pindutin ang 0. Kapag sumagot ang ahente, sabihin ang wika na kailangan mo
at ikokonekta ka sa isang interpreter.
Espaol (Spanish) Atencin: Este aviso contiene informacin sobre su cobertura de seguro. Es posible que
incluya fechas clave y que usted tenga que realizar alguna accin antes de ciertas fechas lmite. Usted tiene
derecho a obtener esta informacin y asistencia en su idioma sin ningn costo. Los asegurados deben llamar al
nmero de telfono que se encuentra al reverso de su tarjeta de identificacin. Todos los dems pueden llamar al
855-258-6518 y esperar la grabacin hasta que se les indique que deben presionar 0. Cuando un agente de seguros
responda, indique el idioma que necesita y se le comunicar con un intrprete.
(Russian) !
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.
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.
855-258-6518 , 0.
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CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., CareFirst BlueChoice, Inc., First Care, Inc. and The Dental Network are independent licensees of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association.
Registered trademark of CareFirst of Maryland, Inc.
(Hindi) : - 855-258-6518 0 ,
s-w (Bassa) To uu Cao! B nia k a ny e ke m gbo kpa o ni fu a-fa-tiin ny je dyi. B nia k
ee we j e m ke wa m m ke nyu nyu hw we ea ke zi. m ni kpe m ke b nia k ke gbo-
kpa-kpa m m dye e ni ii-wuu mu m ke se wii o p. Kpoo ny e m a fn-na nia e waa
I.D. kaa ein ny. Ny t sein m a na nia k: 855-258-6518, ke m m fo tee wa ke m gbo c m ke
na ma 0 k dyi paain hw. ju ke ny o dyi m g juin, po wuu m m po dyi, ke ny o mu o niin
ke ni wuu mu za.
(Bengali) : 855-258-6518 0
: (Urdu )
0 6518-258-855
: . (Farsi ). .
.
. 0 855-258-6518
.
: (Arabic) . .
.
.0 855-258-6518
.
(Traditional Chinese)
855-258-6518
0
CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., CareFirst BlueChoice, Inc., First Care, Inc. and The Dental Network are independent licensees of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association.
Registered trademark of CareFirst of Maryland, Inc.
Igbo (Igbo) Nrbama: kwa a nwere ozi gbasara mkpuchi nchekwa onwe g. nwere ike nwe bch nd d
mkpa, nwere ike me ihe tupu fd bch njedebe. nwere ikike nweta ozi na enyemaka a nass g na
akwgh gw bla. Nd otu kwesr kp akara ekwent d naz nke kaad njirimara ha. Nd z niile nwere
ike kp 855-258-6518 wee chere bb ah ruo mgbe amanyere p 0. Mgbe onye nnchite anya zara, kwuo
ass chr, a ga-ejik g na onye kwa okwu.
Deutsch (German) Achtung: Diese Mitteilung enthlt Informationen ber Ihren Versicherungsschutz. Sie kann
wichtige Termine beinhalten, und Sie mssen gegebenenfalls innerhalb bestimmter Fristen reagieren. Sie haben
das Recht, diese Informationen und weitere Untersttzung kostenlos in Ihrer Sprache zu erhalten. Als Mitglied
verwenden Sie bitte die auf der Rckseite Ihrer Karte angegebene Telefonnummer. Alle anderen Personen rufen
bitte die Nummer 855-258-6518 an und warten auf die Aufforderung, die Taste 0 zu drcken. Geben Sie dem
Mitarbeiter die gewnschte Sprache an, damit er Sie mit einem Dolmetscher verbinden kann.
Franais (French) Attention: cet avis contient des informations sur votre couverture d'assurance. Des dates
importantes peuvent y figurer et il se peut que vous deviez entreprendre des dmarches avant certaines chances.
Vous avez le droit d'obtenir gratuitement ces informations et de l'aide dans votre langue. Les membres doivent
appeler le numro de tlphone figurant l'arrire de leur carte d'identification. Tous les autres peuvent appeler le
855-258-6518 et, aprs avoir cout le message, appuyer sur le 0 lorsqu'ils seront invits le faire. Lorsqu'un(e)
employ(e) rpondra, indiquez la langue que vous souhaitez et vous serez mis(e) en relation avec un interprte.
(Korean) : . .
. ID .
855-258-6518 0 .
.