IN-NETWORK BENEFITS
BENEFITS CONTINUED
FREQUENCY - ONCE EVERY:
Eye Health Examination inclusive of Dilation(when professionally indicated)
Eyeglasses
Contact Lenses (in lieu of eyeglasses)
COPAYMENTS
Eye Health Examination
Eyeglasses
Contact Lenses (in lieu of eyeglasses)
EYEGLASS BENEFIT - FRAME
Non-Collection Frame Allowance (Retail)
The Exclusive Collection /1 (in lieu of Allowance):
Fashion Selection
Designer Selection
Premier Selection
EYEGLASS BENEFIT - SPECTACLE LENSES MEMBER CHARGES
Plastic or Glass Single-Vision, Bifocal or Trifocal Lenses (any Rx)
Scratch-Resistant Coating
Polycarbonate Lenses
Ultraviolet Coating
Intermediate-vision lenses
Glass Grey #3 Prescription Lenses
COURT OFFICERSBENEVOLENTASSOCIATIONOF NASSAU COUNTY, INC.
RETIREE
Every Calendar Year
Every Calendar Year
Every Calendar Year
$0
$0
$0
$0
Oversize Lenses $0
Post-cataract Lenses $0
Tinting of Plastic Lenses $0
$30
$0
$30
$12
$0
Covered-in-full
$130 allowanceplus 20% off overage
Covered-in-full
$25
/2
Polarized Lenses $75
IN-NETWORK BENEFITS
EYEGLASS BENEFIT - SPECTACLE LENSES (CONTINUED) MEMBER CHARGES
/3
Standard progressive addition multifocal lenses
Premium Progressive Addition Multifocal Lenses
/3
/4
/4
Ultra Progressive Addition Multifocal Lenses
Anti-Reflective Coating (Standard / Premium / Ultra)
$90
$140
Scratch Protection Plan (Single Vision / Multifocal) $20 / $40
$35 / $48 / $60
Plastic Photochromic Lenses $65
High-Index Lenses $55
CONTACT LENS BENEFIT
Non-Collection Contact Lenses: Materials Allowance
- Evaluation, Fitting & Follow-Up Care Allowance - Specialty Lens Types
The Exclusive Collection of Contact Lenses /1
(in lieu of Allowance):
(IN LIEU OF EYEGLASSES)
Materials - Disposable - Planned Replacement - Evaluation, Fitting & Follow-up Care
Four boxes / multi-packsTwo boxes / multi-packs
Covered
Visually Required Contact Lenses (with prior approval) - Materials, Evaluation, Fitting & Follow-up Care Covered
1/Collection is available at most participating provider offices. Collection is subject to change. All contact lenses in the Collection are single-vision spherical lenses.
Davis Vision has done its best to accurately reflect plan coverage herein. If differences exist between this document and the plan contract, the contract will prevail.
4/Number of contact lens boxes may vary based on manufacturer’s packaging.
3/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; however, the copayment will not be refined.
1 (800) 999-5431DAVISVISION.COM#DAVISVISIONFollow us online
COBANC3_BNFT_112117
ADDITIONAL INFORMATION
$50
$130 allowance plus 15% off overage
$60 allowance plus 15% off overage
/3
Value-Added Services for Vision
• 1-year breakage warranty included on frames from the Davis Vision Exclusive Collection.
• Discounts on LASIK procedures. Visit www.davisvision.com or call 855-502-2020 for information.
• Convenient network locations throughout the 50 states.
• U.S.-based call center available 7 days per week.
• Replacement contacts (after initial benefit) via davisvisioncontacts.com mail-order service.
• Virtually try on and compare new frame styles at any time from your desktop or mobile device by visiting
www.davisvision.com.
Hearing Aids
• Davis Vision members can receive 30%-60% off the cost of brand name hearing aids through Ear Professionals
International Corporation (EPIC), which saves $1,000 on average.
• You must use a participating audiologist or otolaryngologist (ENT).
• For more information, call 844-246-0544 or visit www.epichearing.com/davisvision.
2/Polycarbonate lenses are covered in full for dependent children, monocular patients and patients with presciptions +/- 6.00 diopters or greater.