VISION BENEFIT

SCHEDULE OF BENEFITS

Vision Benefit Administered by Medical Eye Services (MES)

BENEFITS

The following vision care benefits are provided for all active participants. (Coverage for self-pay participants may be different. Please see the “Extended Coverage” section of this booklet). Covered services and/or materials when you go to an Eye Care Network participating provider include:

1. Vision examination every 12 months;
2. One pair of standard lenses every 12 months with prescription change*, otherwise, every 24 months (standard lenses fit any frame with an eye size less than 61mm);
3. One standard frame every 24 months (a standard frame is any frame that has a maximum retail cost of $75 or less); and
4. One pair of contact lenses every 12 months with prescription change*, otherwise, every 24 months.

1. A change in the prescription of 0.50 diopter or more in one or both eyes;
2. A shift in axis of astigmatism of 15 degrees; or
3. A difference in vertical prism greater than 1 prism diopter.

If contact lenses are for cosmetic or convenience purposes, the Plan will pay up to $150 towards the contact lens evaluation, fitting costs and materials. Any balance is your responsibility.

If contact lenses are medically necessary, they are a fully covered benefit following cataract surgery; or when visual acuity cannot be corrected to 20/70 in the better eye except through the use of contacts; or when necessitated by anisometropia or certain conditions of keratoconus. Prior authorization from Medical Eye Services is required.

When you select a provider from the participating provider list, the vision benefits described above (examination, professional services, lenses, and frames) will be provided. Any additional care, service and/or materials not covered by this plan may be arranged between you and the provider.

HOW TO USE THE PLAN

Obtain an MES claim form and listing of participating providers from the Administrative Office. Make sure you are eligible for vision benefits.

After you obtain your MES claim form, make an appointment with the eye care specialist of your choice. With Part 1 of the claim form completed, present it to the provider at the time of your visit.

Participating providers will submit the claim form to MES and will be paid directly. If you do not bring your claim form with you at the time of your visit, you may be required to pay in full for the services.

If services are received from a non-participating provider, reimbursement will be made to the insured, up to the Schedule of Allowances. You or the provider should submit an itemized bill and a copy of your prescription with the claim form to MES.

Reimbursement Schedule for Non-Participating Providers

Professional fees:

1. Vision examination, $40 allowance

1. Single vision lenses, up to $52.00;
2. Bifocal lenses up to $72.50;
3. Trifocal lenses, up to $89.50;
4. Lenticular or aphakic lenses, up to $125.00 or $200.00, depending on the prescription;
5. Progressive lenses up to $125.00;
6. Frame, up to $40.00; and
7. Contact lenses:
1. Cosmetic or convenience, up to $150.00,
2. Medically necessary, up to $250.00.

LIMITATIONS

1. Contact lenses, except as specifically provided;
2. Contact lens fitting, except as specifically provided;
3. Eyewear when there is no prescription change, except when benefits are otherwise available;
4. Lenses or frames that are lost, stolen or broken will not be replaced, except when benefits are otherwise available;
5. Lenses such as no-line (blended type), progressive, beveled, faceted, coated or oversize exceeding the allowance for covered lenses;
6. Tints, other than pink or rose #1 or #2, except as specifically provided; and
7. Two pair of glasses in lieu of bifocals, unless prescribed.

EXCLUSIONS

1. Any eye examination required by an employer as a condition of employment;
2. Conditions covered by Workers’ Compensation;
3. Contact lens insurance or care kits;
4. Covered services which begin prior to the insured’s effective date or after benefits have been terminated;
5. Covered services for which the insured is not legally obligated to pay;
6. Covered services required by any government agency or program, federal, state or subdivision thereof;
7. Covered services performed by a close relative or by an individual who ordinarily resides in the insured’s home;
8. Medical or surgical treatment of the eyes;
9. Non-prescription (plano) eyewear;
10. Orthoptics, vision training or sub-normal vision aids;
11. Services that are experimental or investigational in nature; and
12. Services for treatment directly related to any totally disabling condition, illness or injury.

If you have any questions about the plan, please contact:

Medical Eye Services
P.O. Box 93033
Long Beach, California 90809
(562) 496-1878 or (800) 877-6372

This is a brief outline of the plan and is not to be accepted or construed as a substitute for the provisions of the contract.