Hughston MetLife Plan Materials

Exclusions and Limitations of Benefits This plan does not cover the following services, materials and treatments:

Services and Eyewear

• Services and materials obtained while outside the United States, except for emergency vision care. • Services, procedures, or materials for which a charge would not have been made in the absence of insurance. • Services: (a) for which the employer of the person receiving such services is not required to pay; or (b) received at a facility maintained by the Employer, labor union, mutual benefit association, or VA hospital. • Services, to the extent such services, or benefits

• Contact lens insurance policies and service agreements. • Refitting of contact lenses after the initial (90 day) fitting period. • Contact lens modification, polishing, and cleaning. Treatments • Orthoptics or vision training and any associated supplemental testing. • Medical and surgical treatment of the eye(s).

• Services and/or materials not specifically included in the Vision Plan Benefits Overview (Schedule of Benefits). • Any portion of a charge above the Maximum Benefit Allowance or reimbursement indicated in the Schedule of Benefits. • Any eye examination or corrective eyewear required as a condition of employment. • Services and supplies received by you or your Dependent before the Vision Insurance starts. • Missed appointments. • Services or materials resulting from or in the course of a Covered Person’s regular occupation for pay or profit for which the Covered Person is entitled to benefits under any Workers’ Compensation Law, Employer’s Liability Law or similar law. You must promptly claim and notify the Company of all such benefits. • Local, state and/or federal taxes, except where MetLife is required by law to pay. • Services or materials received as a result of disease, defect, or injury due to war or an act of war (declared or undeclared), taking part in a riot or insurrection, or committing or attempting to commit a felony. 1 All lens enhancements are available at participating private practices. Maximum copays and pricing are subject to change without notice. Please check with your provider for details and copays applicable to your lens choice. Please contact your local Costco, Walmart and Sam’s Club to confirm availability of lens enhancements and pricing prior to receiving services. Additional discounts may not be available in certain states. 2 Custom LASIK coverage only available using wavefront technology with the microkeratome surgical device. Other LASIK procedures may be performed at an additional cost to the member. Additional savings on laser vision care is only available at participating locations.

for such services, are available under a Government Plan. This exclusion will apply

whether or not the person receiving the services is Medications

• Prescription and non-prescription medication

enrolled for the Government Plan. We will not exclude payment of benefits for such services if the Government Plan requires that Vision Insurance under the Group Policy be paid first. Government Plan means any plan, program, or coverage which is established under the laws or regulations of any government. The term does not include any plan, program, or coverage provided by a government as an employer or Medicare. • Plano lenses (lenses with refractive correction of less than ± .50 diopter). • Two pairs of glasses instead of bifocals. • Replacement of lenses, frames and/or contact lenses, furnished under this Plan which are lost, stolen, or damaged, except at the normal intervals when Plan Benefits are otherwise available.

Important: If you or your family members are covered by more than one health care plan, you may not be able to collect benefits from both plans. Each plan may require you to follow its rules or use specific doctors and hospitals, and it may be impossible to comply with both plans at the same time. Before you enroll in this plan, read all of the rules very carefully and compare them with the rules of any other plan that covers you or your family. M130D-10/20 MetLife Vision benefits are underwritten by Metropolitan Life Insurance Company, New York, NY. Certain claims and network administration services are provided through Vision Service Plan (VSP), Rancho Cordova, CA. VSP is not affiliated with Metropolitan Life Insurance Company or its affiliates. Like most group benefit programs, benefit programs offered by MetLife and its affiliates contain certain exclusions, exceptions, reductions, limitations, waiting periods, and terms for keeping them in force. Please contact MetLife or your plan administrator for costs and complete details.

VI-STAND Vision Benefit Summary

Made with FlippingBook - professional solution for displaying marketing and sales documents online