Vision Benefits** Please be aware that the Vision network is different from the network of your medical and/or dental benefits. Covered Expenses For You and Your Dependents Benefits Include: Examination(s) Comprehensive Examination - One vision and eye health evaluation including but not limited to eye health examination, dilation, refraction and prescription for glasses. Retinal Screening – One retinal imaging, which takes digital pictures of the inside of the eye. Does not replace a dilate eye examination. Must be in conjunction with an eye Examination. Contact Lens Professional Services (Fit & Follow-up) – All fitting and evaluation services provided by a Vision Provider. Available when an eye Examination has been completed. Materials Vision Materials Coverage Eyeglass Lenses (Glasses) – One pair of prescription plastic or glass lenses, all ranges of prescriptions (powers and prisms). • Clear or sun lenses. • Polycarbonate lenses for children under 19 years of age. • Oversize eyeglass lenses. • Rose #1 and #2 solid tints. • Coverage for One of the following eyeglass lens types:
obtain this level of visual acuity; and in certain cases of anisometropia, keratoconus, or aphakis; as determined and documented by your Vision Provider. Contact lenses fitted for other therapeutic purposes or the narrowing of visual fields due to high minus or plus correction will be covered in accordance with the Elective contact lens benefit shown on the Schedule of Benefits. OTHER OPTIONAL VISION BENEFITS: **coverage may vary at participating discount retail and membership club optical locations, please contact Customer Service for specific coverage information.
HCVIS-COV0
01-24
Vision Benefits For You and Your Dependents Exclusions Vision Expenses will not include, and no payment will be made for: • Orthoptic or vision training and any associated supplemental testing. • Medical or surgical treatment, services or supplies for the treatment of the eyes or supporting structures. • Refraction, when not provided as part of a Comprehensive Eye Examination. • Any eye examination, or any corrective eyewear, required by an employer as a condition of employment. • Charges incurred after the Policy ends or the insured's coverage under the Policy ends, except as stated in the Policy. • Services rendered after the date a Covered Person ceases to be covered under the Policy, except when Vision Materials are ordered before coverage ended and are delivered within 31 days from date of such order. • Experimental or non-conventional treatment or device. • Charges in excess of the usual and customary charge for the service or materials. • For or in connection with experimental procedures or treatment methods not approved by the American Optometric Association or the appropriate vision specialty society. • Any injury or illness when paid or payable by Workers’ Compensation or similar law, or which is work-related.
• Single Vision Eyeglass Lenses (pair) • Lined Bifocal Eyeglass Lenses (pair) • Lined Trifocal Eyeglass Lenses (pair) • Lenticular Eyeglass Lenses (pair)
• Progressive lenses covered up to bifocal lens amount. Frames – One frame - choice of frame covered up to retail plan allowance. Contact Lenses and Professional Services – One pair or a single purchase of a supply of contact lenses in lieu of eyeglass lenses and frame benefit (may not receive eyeglass lenses, contact lenses and frames in same benefit year). Contact lens retail allowance can be applied towards contact lens materials as well as the cost of supplemental contact lens professional services including fitting and evaluation, up to the stated allowance. Coverage for Therapeutic contact lenses will be provided when visual acuity cannot be corrected to 20/70 in the better eye with eyeglasses and the fitting of the contact lenses would
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