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Vision Care Plan Benefit Description


Wappingers Congress of Teachers Welfare Trust Fund is very pleased to provide this information about your vision care plan administered by Davis Vision, Inc., a leading national administrator of routine vision care programs. Eligibility for vision care benefits is determined by the same rules that apply to your other health care benefits.

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 member or covered dependent of the Wappingers Congress of Teachers Welfare Trust Fund.

• Provide the offce with the member's Identification number and the date of birth of any covered children needing services,

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

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 1-800-999-543 I 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 Doctor" feature.

What are the plan benefits, frequencies and costs?

EYE EXAMINATIONS..Every 12 months, including dilation as professionally indicated. In Network Copayment..None Out-of-Network..Reimbursement up to $30.00

SPECTACLE LENSES..Every 12 months In-Network Copayment..None. You may select a frame from the Premier selection in the exclusive "Tower Collection" available in most network provider offices. A $56.19 credit will be applied toward a network providers own frame. Out-of-Network..Reimbursement up to $30.00 for frames, up to $25.00 for single vision lenses. $35.00 for bifocals, $45.00 for trifocals, $45.00 for- lenticular (post-cataract) lenses

CONTACT LENSES..Every 12 months In-Network Copayment..None. Standard, soft, daily-wear, disposable. or planned replacement contact lenses may be selected in lieu of eyeglasses. A $100.00 credit will be applied toward contact lenses from the provider's own supply (which may or may not apply toward fittinglfollow-up care fees). Medically necessary contact lenses for the correction of Keratoconus are covered up to $500.00 with prior approval. Out-of-Network..Reimbursement up to $75.00 for cosmetic contact lenses, up to $225.00 for medically necessary contact lenses for the correction of Keratoconus with prior approval.

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

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

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.
• Scratch-resistant coating.
• Photogrey Extra@ (photosensitive) glass lenses.
• Blended invisible bifocals.
• Ultraviolet (UV) coating.
• Polycarbonate (impact resistant) lenses.
• Standard and premium anti-reflective coating (ARC).
• Polarized lenses.
• Plastic photosensitive lenses.
• High-index (thinner and lighter) lenses.
• Intermediate vision lenses.
• Progressive addition multifocals.**

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

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, anti-reflective coating (ARC), specialized prescriptions or non "Tower 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
PO. Box 1525
Latham, NY 12110

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

May I use the benefit at different times?

To maintain continuity of care, we recommend that all services be obtained at one time from either a network or an out-of-network provider.

Information about Low Vision Services:

You and your covered dependents are entitled to a comprehensive low vision evaluation once every five years and low vision aids up to the plan maximum. Up to four follow-up care visits will be covered during the five year period.

Information about LaserVision Correction Services:

Davis Vision is pleased to provide you and your eligible family members with the opportunity to receive LaserVision Correction Services at significant discounts through a network of experienced, credentialed surgeons (please note that some providers have flat fees equivalent to these discounts). For more information, please visit our website at www.davisvision.com or call 1-800-999-5431.

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 ( I-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.

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.
• Replacement of lost eyewear.
• Non-prescription (plano) lenses.
• Services not performed by licensed personnel.

For more information, please visit Davis Vision's website at www.davisvision.com or call DavisVision at I-800-999-5431 to:

• Learn about the DavisVision company.
• Access the Interactive Voice Response Unit which will provide network providers nearest you.
• Verify eligibility for yourself or your dependents.
• Request an out-of-network provider reimbursement form.
• Understand emergency care.
• Speak with a Member Service Representative.
• Ask any questions about yourVision Care benefits.

Member Service Representatives are available:

• Monday through Friday, 8:00 AM to 8:00 PM, Eastern Time, and;
• Saturday, 9:00 AM 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.