Vision

Vision Benefits by Avesis     

Check your Vision Benefits – 800-584-4214

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

In-Network Benefits

Group Details – DCBOE
Group # 30813-08
Plan # 924
Effective Date: 01-01-2013

Benefit Frequency

Vision Exam               12 Months
Spectacle Lenses       12 Months
Frames                        12 Months
Contact Lenses           12 Months

Co-Pays

Vision Examination   $10.00
Materials                     $10.00

Rates

Employee Only           $   5.95
Employee + One         $ 10.38
Employee + Family    $ 15.28

Out-of-Network Reimbursement – Below

Exam                                                 $35.00
Standard Single Vision                  $25.00
Standard Bifocal                             $40.00
Standard Trifocal                           $50.00
Standard Lenticular                       $80.00
Progressive                                     $40.00

Corresponding Standard Lens Reimbursement

Frame                                                           $  45.00
Contact Lenses (Elective)                        $130.00
Contact Lenses (Med. Necessary)          $250.00
LASIK Surgery                                           $150.00

 In Network Benefits

Your vision exam is covered in full after a co-pay
$200.00* Average Retail – See Brochure
When choosing the frames & spectacle lenses package

SPECTACLE LENSES – Standard lenses are covered in full Providers typically charge between $60.00-$120.00 for standard lenses.

Frames – Providers typically charge between $100-$150.00 for frames covered in full by your plan allowance

Contact Lenses – In lieu of frames and spectacle lenses, members receive an allowance up to $130 for materials and fit and follow-up exam.  Medically necessary contact lenses are covered in full (prior authorization is required)

LASIK Surgery
– Members receive a one-time/lifetime allowance of $150 – LASIK Surgery – 5% – 25% off retail

Additional Discounts

Progressive Lenses – Are discounted up to 20% off retail in addition to a $50 allowance

Specialty Lenses – Are discounted up to 20% off retail in addition to the corresponding standard lens allowance

Lens Options, Non-Covered Items and Additional Purchases are discounted up to 20% off retail

Standard Trifocal Standard Lenticular Progressive Specialty Lenses

Corresponding Standard Lens Reimbursement

Frame                                                         $  45.00
Contact Lenses (Elective)                        $130.00
Contact Lenses (Med. Necessary)          $250.00
LASIK Surgery                                           $150.00

www.avesis.com

Using your Vision Benefit

When you need to see an eye care professional, simply visit www.avesis.com or contact Avesis’ Customer Service Monday through Friday, 7AM to 8PM (EST) at 1-800-828-9341 to receive a listing of providers in your area

1   Select a provider
2   Contact provider for an appointment
3   Visit provider for service
4   Pay any co-pays or additional uncovered expenses

Important Information

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

Using Out-Of-Network Providers

Members who elect to use an out-of-network provider must pay the provider in full at the time of service and submit a claim to Avesis for reimbursement. Reimbursement levels are in accordance with the out-of-network reimbursement schedule previously listed. Out-of-network benefits are subject to the same eligibility, availability, frequency of benefits, and limitation and exclusion provisions of the plan; and are in lieu of services provided by a participating Avesis provider. Out-of-network claim forms can be obtained by contacting Avesis’ Customer Service Center, your group administrator or by visiting www.avesis.com.

Notes and Disclaimers

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

The contact lens allowance may be used all at once or throughout the plan year as needed or may be applied toward contact lenses only, or both contact lenses and professional services (fitting fees).

Laser vision correction is considered Refractive Surgery, an elective 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 employment ends, or the date the employee is no longer eligible.

**Provider wholesale frame pricing for your plan is $50. Participating Wal-Mart locations cover frames up to a $68 retail value.

*  Values provided may be more or less depending on the providers retail pricing.

Vision Brochure
Vision Application – Online  
Vision Application
Vision Out of Network Claim Form

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