Vision Care Coverage

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This plan provides Vision Care benefits. To assure you the best possible use of your benefit, please take a few minutes to review the

information in this booklet.

How do I receive services from a provider in the network?

• Call the network provider of your choice and schedule an appointment.

• Identify yourself as a Davis Vision plan participant and a NYSUT member or covered dependent*.

• Provide the office with the member’s ID number and the date of birth of any covered children needing services.

It’s that easy! The provider’s office will verify your eligibility for services, and no claim forms or ID cards are required!

* Dependent coverage is available if family coverage was purchased. Dependents are your spouse and dependent children, who include: Natural and legally adopted children, and any other

children who permanently reside in your household. Coverage is available until age 19. Coverage will continue until age 25 with appropriate full-time student identification.

Who are the network providers?

They are licensed providers who are extensively reviewed and credentialed to ensure that stringent standards for quality service are

maintained. Please call 1-800-999-5431 to access the Interactive Voice Response (IVR) Unit, which will supply you with the names and addresses of the network providers nearest you, or you may access our website at www.davisvision.com and utilize our “Find a

Provider” feature.

What are the plan benefits,

frequencies and costs?

EYE EXAMINATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Every 12 months,

including dilation if professionally indicated.

Copayment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . None

Out-of-Network . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Reimbursed up to $10

SPECTACLE LENSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Every 12 months

Copayment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . None

Out-of-Network . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . See ** Below

FRAMES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Every 12 months

Copayment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . None.

You may choose a frame from “The Collection” (Designer selection) available in most network provider offices. A $50 credit will be applied

toward a network provider’s own frame.

Out-of-Network . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . See ** Below

CONTACT LENSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Every 12 months

Copayment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . None.

Standard, soft, daily-wear, disposable*** or planned replacement*** contact lenses may be selected in lieu of eyeglasses. A $100 credit will

be applied toward contact lenses from the provider’s own supply, fitting fees and recommended follow-up care. Prior approval

is required for medically necessary contact lenses.

Out-of-Network . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . See ** Below

Please note: Contact lenses can be worn by most people. Once the contact lens option is selected and the lenses are fitted, they may not be exchanged for eyeglasses. Routine eye examinations may not include professional services for contact lens evaluations. Any applicable fees are the responsibility of the patient.

** All non-medically necessary materials (frame and/or spectacle / contact lenses) will be reimbursed up to $35. Medically necessary contact lenses will be reimbursed up to $350.

*** Disposable contact lens wearers will receive a four multi-pack supply of lenses. Planned replacement contact lens wearers will receive a two multi-pack supply.

Vision Care Plan Benefit Description

Please call Davis Vision at 1-800-999-5431 with questions or visit our website: www.davisvision.com

SP00089web 5/5/08 5N

Annual Services

(from last date of service)

Designer Plan

What lenses/coatings are included?

• Plastic or glass single vision, bifocal or trifocal lenses, in any prescription range.

• Glass grey #3 prescription lenses.

• Oversize lenses.

• Post-cataract lenses.

• Fashion, sun or gradient tinted plastic lenses.

• Polycarbonate lenses for dependent children, monocular patients, and patients with prescriptions of +/- 6.00 of diopters or greater.

Are there any optional frames, lens types or coatings available?

Yes, you can pay the low, discounted fixed fees indicated and receive these exciting optional items:

• $20 for a premier frame.

• $35 for standard brands of ARC (anti-reflective coating). Premium ARC is $48. Ultra ARC is $60.

• $78 for pinnacle single vision lenses.

• $158 for pinnacle progressive lenses.

• $48 for pinnacle single vision lenses (dependent children, monocular patients, and patients with prescription of +/- 6.00 of diopters

or greater).

• $128 for pinnacle progressive lenses (dependent children, monocular patients, and patients with prescription of +/- 6.00 of diopters

or greater).

• $75 for polarized lenses.

• $65 for plastic photosensitive lenses.

• $55for high-index (thinner and lighter) lenses.

• $20 for scratch-resistant coating.

• $20 for Photogrey Extra® (photosensitive) glass lenses.

• $30 for polycarbonate lenses.

• $30 for intermediate vision lenses.

• $12 for ultraviolet (UV) coating.

• $20 for blended invisible bifocals.

• $50 for standard brands of progressive addition multifocal lenses. Premium brands are $90.*

* Progressive addition multifocals can be worn by most people. Conventional bifocals will be supplied at no additional charge for anyone who is unable to adapt to progressive addition

lenses; however, your copayment will not be refunded.

May I use the benefit at different times?

All services must be obtained at one time from either a network or an out-of-network provider.

When will I receive my eyewear?

Your eyewear will be sent to your provider from the laboratory generally within two to five business days. More delivery time may be

needed when out-of-stock frames,ARC (anti-reflective coating), specialized prescriptions or non “Collection” frames are selected.

What about out-of-network provider benefits?

You may receive services from an out-of-network provider, although you will receive the greatest value and maximize your benefit dollars

if you select a provider who participates in the network. If you choose an out-of-network provider, you must pay the provider directly for

all charges and then submit a claim for reimbursement to:

Vision Care Processing Unit

P.O. Box 1525

Latham, NY 12110

All services should be submitted at the same time, as only one claim for reimbursement may be submitted per benefit cycle.To request

claim forms, please visit the Davis Vision website at www.davisvision.com or call 1-800-999-5431.

Information about Laser Vision Correction Services:

Davis Vision provides you and your eligible dependents with the opportunity to receive Laser Vision Correction Services at discounts of

up to 25% off a participating provider’s normal charges, or 5% off any advertised special (please note that some providers have flat fees

equivalent to these discounts). Please check the discount available to you with the participating provider. For more information, please

visit us at www.davisvision.com or call 1-800-584-2866, and enter client code 7077.

More special features:

• Free membership and access to a mail order replacement contact lens service, Lens 123, providing a fast and convenient way to

purchase replacement contact lenses at significant savings. For more information, please call 1-800-LENS-123 (1-800-536-7123) or visit the Lens 123 website at www.Lens123.com.

• A one-year unconditional breakage warranty is provided for all eyeglasses completely supplied by Davis Vision.

Continuation of coverage through COBRA (Self-Pay):

In accordance with the provisions of the Consolidated Omnibus Budget Reconciliation Act (COBRA), should your coverage for vision care benefits stop, you and your eligible dependents may be able to continue your vision care benefits pursuant to COBRA.

If your vision care benefits coverage terminates, you must inform immediately the provider of your vision care benefits (your employer,

your local union, or your local union’s welfare benefit fund) of your desire to continue your vision care coverage pursuant to COBRA.

Are there any exclusions?

The following items are not covered by this vision program:

• Medical treatment of eye disease or injury.

• Vision therapy.

• Special lens designs or coatings, other than those previously described.

• Non-prescription (plano) lenses.

• Replacement of lost eyewear.

• Two pairs of eyeglasses, in lieu of bifocals.

• Contact lenses and eyeglasses in the same benefit period.

For more information, please visit Davis Vision’s website at www.davisvision.com or call Davis Vision

at 1-800-999-5431 to:

• Locate a network provider in your area.

• Verify eligibility for yourself or a family member.

• Request an out-of-network claim form.

• Speak with a Member Service Representative.

• Ask any questions about your Vision Care benefits.

Member Service Representatives are available:

• Monday through Friday, 8:00 am to 11:00 pm, Eastern Time,

• Saturday, 9:00 am to 4:00 pm Eastern Time, and;

• Sunday, 12:00 pm to 4:00 pm Eastern Time.

Participants who use a TTY (Teletypewriter) because of a hearing or speech disability may access TTY services by calling 1-800-523-2847.

Your rights as a patient:

Davis Vision recognizes that all patients have specific rights, including, but not limited to:

• The right to complete information about their healthcare options and consequences.

• The right to participate in all treatment decisions.

• The right to dignity, privacy, confidentiality and non-discrimination.

• The right to complain or appeal any decision.

Patients also have the responsibility:

• To provide complete and accurate information.

• To follow care instructions.

For a complete copy of Your Rights and Responsibilities As a Patient, please visit our website at: www.davisvision.com or call 1-800-999-

5431.

For general information about your Vision Care benefits, please call or e-mail:

NYSUT Member Benefits Trust

Telephone: (800) 626-8101

E-mail: benefits@nysutmail.org

The Group Vision Plan is a NYSUT Member Benefits Trust (Member Benefits)-endorsed program. Member Benefits self-insures the risk for groups

with guaranteed rate contracts, meaning total premiums collected and claims paid are pooled annually. At the end of the plan year, any surplus funds

revert to Member Benefits; if a deficit exists, Member Benefits is responsible for covering the loss. For the last 10-year period, a surplus equaling

approximately 4.1% of paid premiums has resulted. For self-insured group vision plans, Member Benefits has an expense

reimbursement/endorsement arrangement of $.07 per month per enrolled participant. All such payments to Member Benefits are used solely to defray the costs of administering its various programs and, where appropriate, to enhance them.The insured group vision plans pool the premiums of Member Benefits participants who are insured for the purposes of determining premium rates and accounting. Coverage outside of this plan may have rates and terms that are not the same as those obtainable through Member Benefits.The Insurer or Member Benefits may hold premium reserves that may be used to offset rate increases and/or fund such other expenses related to the plan as determined appropriate by Member Benefits. Member Benefits acts as your advocate; please contact Member Benefits at (800) 626-8101 if you experience a problem with any endorsed program.