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

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Polarized Lenses $75

IN-NETWORK BENEFITS

EYEGLASS BENEFIT - SPECTACLE LENSES (CONTINUED) MEMBER CHARGES

/3

Standard progressive addition multifocal lenses

Premium Progressive Addition Multifocal Lenses

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/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

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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.