Cobb County School District Vision Summary of Benefits

Cobb County School District Vision Summary of BenefitsCobb County School District offers two vision plans through Avesis, a basic plan and a preferred plus plan to help pay for routine vision services and supplies. In both vision plans, when you use an Avesis provider, you pay a co-pay and then many services are covered at 100% up to the plan allowance. If you use an out-of-network provider, you will be required to pay the full amount of your vision care bill at the time of service. After you visit, you need to submit a copy of the itemized bill to Avesis for reimbursement.

For more details regarding vision benefits or to find an in-network provider, please visit www.avesis.com/members.html.

SERVICE

Examination Benefits Covered in full after Co-Pay

$10 Co-Pay

Comprehensive Eye HealthExamination

• Covered in Full after Exam Co-pay• Every 12 Months• $40 allowance out of network

Contact Lens Coverage*†

Frame Benefit* • $45 Allowance • Every 12 Months

MATERIALS COVERAGE

• $110 Elective Allowance Every 12 Months (Covered in full if medically necessary)

$25 Co-Pay

$110 Allowance

• The Plan pays $50 wholesale (approximate retail value is $100-$150)• Member will pay reduced (less than full retail cost) fee if the frame allowance is exceeded• Every 24 months

None

Spectacle Lens Benefit*

Single - Bifocal - Trifocal - Lenticular -

Standard Single VisionStandard BifocalStandard TrifocalStandard LenticularCovered in full after Co-PayProgressive $50 allowance + discount

Lasik Coverage Discounted Services Available

Discounted Services Available+ $150 Lasik allowance None

CCSD EMPLOYEE MONTHLY PRE-TAX RATES

Employee ONLY

Employee + FAMILY

$1.08

$2.70

$4.72

$13.10

* Please note, if purchased in-network, discounted prices may be offered through the Avesis Vision Plan. However, as with most products, retail prices may vary. Discounts are not available at Wal-Mart locations or other select retailers.† If you choose contact lenses, this benefit is provided instead of the benefit for spectacle lenses and frames.

Lens Option Coverage* Discounted Materials up to 20%

• Covered in Full after Exam Co-pay• Every 12 Months

Discounted Materials up to 20% off

• $40 Allowance • Every 12 Months

In-Network In-Network Out of Network

Covered in full after Co-Pay

$20 Co-Pay

Employee + 1 $1.90 $8.82

BASIC PLAN PREFERRED PLUS PLAN

Discounted Materials up to 20% off

Discounted Materials up to 20% off

Discounted Materials up to 20% off

$30$50 $65$80

Allowances:

Progressive - $40

HOW THE PLAN WORKS — ACCESSING PLAN BENEFITS IS EASY!

EXAMPLE 1 - EMPLOYEE ONLY

Exam

BASIC PLAN PREFERRED PLUS PLAN

$85 $20

Frame $120

RETAIL

$10

$25$96

Lens $50 $40

Scratch Coating $25

$0

$20$20

TOTAL COST* $280 $55$176

TOTAL SAVINGS $225$104

Exam

BASIC PLAN PREFERRED PLUS PLAN

$85

Frame $150

RETAIL

Cost Per Member $310

TOTAL SAVINGS

EXAMPLE 2 - FAMILY

Mom Dad Jr.

$85

$125

$435

$85

$110

$270

Scratch Coating $25

$20

$120

$200

Mom Dad Jr.

$20

$100

$300

$20

$88

$168

$10

$25

$55

Mom Dad Jr.

$10

$25

$165

$10

$25

Lens $50 $200 $50 $40 $160 $40 $0 $110 $0

$55

$1,015

$740$347

SAVINGS EXAMPLES Why pay retail?

STEP 1: Enroll for coverage during open enrollment. You will need to select one of the offered plans. Avesis will send ID Cards to you at home.

STEP 2: Make an appointment. Once you are enrolled, you can select a network doctor and make an appointment. You can go online to www.avesis.com to access the provider directory and view the plan information anytime or call our Customer Care Center at 1-800-828-9341 (7am-8pm EST, M-F). Identify yourself as a member through Cobb County School System’s vision plan with Avesis.

STEP 3: Arrive at your appointment. The doctor’s office will verify eligibility and plan provisions.

STEP 4: You will be responsible for co-pays plus the cost of upgrades to frames and lenses based on Avesis national wholesale and negotiated prices. You can choose any frame you want. When the frame selected exceeds the allowance you will receive a full credit for the benefit allowance and pay the difference based on Avesis Preferred Discounts.

FAQ [Frequently Asked Questions]

What are the advantages of using a network provider? Avesis’ national network of both independent as well as national and regional retail chain providers provides you with one-stop shopping. You’ll receive eye exams and materials and pay nothing more than your co-pay (cosmetic options and selections exceeding plan allowances will include additional charges).

What if I want to see a provider not in your network? If you prefer, you can visit a non-network doctor. You will pay the doctor’s regular charges, and Avesis will reimburse you according to the plan’s non-network benefit schedule.

Can I nominate doctor to become an in-network provider with Avesis? Yes. A provider nomination form is available — please refer to your employer’s benefits website or contact Avesis for a form.

$668 $275

$25$25 $20 $20 $20 $20 $20 $20

TOTAL COST*

* Does not include premium

CONTACT AVESIS CUSTOMER CARE

Avesis Customer Care1-800-828-93417:00 am — 8:00 pm EST

24/7 Online Access & Informationwww.avesis.com

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.

LIMITATIONS AND EXCLUSIONS

Some provisions, benefits, exclusions or limitations listed herein may vary depending on your state of residence.

Limitations: This plan is designed to cover eye examinations and corrective eyewear. It is also designed to cover visual needs rather than cosmetic options. Should the member select options that are not covered under the plan, as shown in the schedule of benefits, the member will pay a discounted fee to the participating Avesis provider. Benefits are payable only for services received while the group and individual member’s coverage is in force.

Exclusions: There are no benefits under the plan for professional services or materials connected with and arising from: 1) Orthoptics of vision training; 2) Subnormal vision aids and any supplemental testing; 3) Plano (non-prescription) lenses, sunglasses; 4) Two pair of glasses in lieu of bifocal lenses; 5) Any medical or surgical treatment of eye or support structures; 6) Replacement of lost or broken lenses, contact lenses or frames, except when the member is normally eligible for services; 7) Any eye examination or corrective eyewear required by an employer as a condition of employment; 8) Services or materials provided as a result of Workers Compensation Law, or similar legislation, required by any governmental agency whether Federal, State or subdivision thereof.

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.