Vision Examination

FRAMES

SPECTACLE LENSES

AND

Contact Lenses

LASIK Surgery

Additional Discounts

Group Details

Bene�t Frequency

Co-Pays

Rates

Out-of-NetworkReimbursement

www.avesis.com

Your vision health is an important part of complete wellness. Avesis is pleased to present your vision benefits whichare designed to give you and your covered family members the care, value and service to help maintain goodvision and overall health.

Your vision exam is covered in full after a co-pay.

Vision ExamSpectacle LensesFramesContact Lenses

Effective Date:Group Number:Plan #:

Vision ExaminationMaterials

ExamStandard Single VisionStandard BifocalStandard TrifocalStandard LenticularProgressiveSpecialty Lenses

FrameContact Lenses (Elective)Contact Lenses (Med. Necessary)LASIK Surgery

Corresponding StandardLens Reimbursement

Up to:

Medically necessary contact lenses are covered in full (prior authorization is required)

Progressive LensesAre discounted up to 20% off retail inaddition to a $50 allowance

Lens Options, Non-Covered Itemsand Additional PurchasesAre discounted up to 20% off retail

Specialty LensesAre discounted up to 20% off retail in additionto the corresponding standard lens allowance

LASIK Surgery5% - 25% off retail

In-Network Bene�ts

Every:

*

**

City of Tucson (Retiree)

12 Months12 Months

12 Months12 Months

10790-21527/1/2013

926NC

$10.00$10.00

Underwritten by: Fidelity Security Life Insurance Company, Kansas City, MO Policy #: VC-16, Form M-9059

$25.00$40.00$50.00$80.00$40.00

$35.00

$110.00$250.00$300.00

$45.00

$15.45$27.15$39.96

Retiree Paid Quarterly RatesIn lieu of frames and spectacle lenses, members receive anallowance up to $110 for materials and �t and follow-up exam

Members receive a one-time/lifetime allowance of $300.00

Providers typically charge between$75 - $100* for frames covered in fullby your plan allowance.**

Standard lenses are covered in full.Providers typically charge between$60 - $120* for standard lenses.

Retiree OnlyRetiree + OneRetiree + Family

$175*average

retail

Values provided may be more or less depending on theproviders retail pricing.

Provider wholesale frame pricing for your plan is $35.Participating Wal-Mart locations cover frames up to a$52 retail value.

Limitations and Exclusions

Some provisions, benefits, exclusions or limitations listedherein may vary depending on your state of residence.

Limitations: This plan is designed to cover eye examinationsand corrective eyewear. It is also designed to cover visualneeds rather than cosmetic options. Should the member selectoptions that are not covered under the plan, as shown in theschedule of benefits, the member will pay a discounted fee tothe participating Avesis provider. Benefits are payable only forservices received while the group and individual member’scoverage is in force.

Exclusions: There are no benefits under the plan forprofessional services or materials connected with and arisingfrom: 1) Orthoptics of vision training; 2) Subnormal vision aidsand any supplemental testing; 3) Plano (non-prescription)lenses, sunglasses; 4) Two pair of glasses in lieu of bifocallenses; 5) Any medical or surgical treatment of eye or supportstructures; 6) Replacement of lost or broken lenses, contactlenses or frames, except when the member is normally eligiblefor services; 7) Any eye examination or corrective eyewearrequired by an employer as a condition of employment;8) Services or materials provided as a result of WorkersCompensation Law, or similar legislation, required by anygovernmental agency whether Federal, State or subdivision thereof.

Notes and Disclaimers

Notes and Disclaimers: Dilation is covered in full based onthe following conditions: central vision loss, photopsia, floaters,history of ocular surgery, history of ocular trauma, history ofocular disease high myopia or diabetes. If the followingconditions do not apply, members will receive Avesis' Preferred Pricing (20% off retail).

The contact lens allowance may be used all at once orthroughout the plan year as needed or may be applied towardcontact lenses only, or both contact lenses and professionalservices (fitting fees).

Laser vision correction is considered Refractive Surgery, anelective procedure, and may involve potential risks to patients. Avesis is not responsible for the outcome of any refractive surgery.

Only one co-pay applies to either frame or lenses.

Termination Provisions: Coverage will end on the earliest of:the date the policy ends, the date the employee’s employmentends, or the date the employee is no longer eligible.Insured benefits are administered by Avesis Third Party Administrators, Inc., Phoenix, AZ

Important Information

Avesis Website: avesis.comCustomer Service Number: 1-800-828-9341LASIK Provider Number: 1-888-314-4619

Using Out-Of-Network Providers

Members who elect to use an out-of-networkprovider must pay the provider in full at the timeof service and submit a claim to Avesis forreimbursement. Reimbursement levels are inaccordance with the out-of-network reimbursementschedule previously listed. Out-of-network benefitsare subject to the same eligibility, availability,frequency of benefits, and limitation and exclusionprovisions of the plan; and are in lieu of servicesprovided by a participating Avesis provider.Out-of-network claim forms can be obtained bycontacting Avesis’ Customer Service Center, yourgroup administrator or by visiting www.avesis.com.

Using your Vision Benefit

When you need to see an eye careprofessional, simply visit www.avesis.com orcontact Avesis’ Customer Service Mondaythrough Friday, 7AM to 8PM (EST) at1-800-828-9341 to receive a listing ofproviders in your area.

1

2 4

3Select a provider Visit providerfor service

Pay any co-paysor additionaluncoveredexpenses

Contactprovider for anappointment

Your Avesis Vision Plan

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