Page 39 - NAPA 2021-2022

BlueVision Plus

Summary of Benefits (24-month benefit period)

In-Network You Pay In-Network You Pay
EYE EXAMINATIONS (once per 12-month benefit period) CONTACT LENSES (mail order)
1
Routine Eye Examination with $10 copay DavisVisionContacts.com Discounted prices
dilation (per benefit period) Mail Order Contact Lens
FRAMES (once per 24-month benefit period) Replacement Online
Davis Vision Frame Collection No copay for approximately Up to 25% off allowed
400 frames Laser Vision Correction 2 amount or 5% off any
Non-Collection Frame Plan pays up to $130, you advertised special 3
pay balance minus 20% Out-of-Network You Pay
discount 1,2
SPECTACLE LENSES (once per 12-month benefit period) Routine Eye Examination Plan pays $45, you pay balance
with dilation (per benefit
Basic Single Vision $20 copay period)
Lenticular (post-cataract) $20 copay Contact Lens Evaluation, Plan pays $60, you pay balance
Basic Bifocal $20 copay Fitting & Follow-Up Care
Basic Trifocal $20 copay Frames Plan pays $60, you pay balance
CONTACT LENSES (initial supply; once per 12-month benefit Single Lenses Plan pays $52, you pay balance
period, in lieu of spectacle lenses) Bifocal Lenses Plan pays $82, you pay balance
Medically Necessary Contacts No copay with prior approval
Davis Vision Contact Lens No copay Trifocal Lenses Plan pays $101, you pay balance
Collection* Lenticular (post-cataract) Plan pays $181, you pay balance
Other (Non-Collection) Contact Plan pays up to $130, you Eyeglass Lenses
Lenses pay balance minus 15% Medically Necessary Plan pays $285, you pay balance
discount 1,2 Contacts
CONTACT LENS EVALUATION, FITTING AND Elective Contact Lenses Plan pays $112, you pay balance
FOLLOW-UP CARE (once per 12-month benefit period) Elective Bifocal Contact Plan pays $127, you pay balance
Davis Vision Collection, $20 copay Lenses
Standard Contact Lenses and
Medically Necessary Contact *The Davis Vision contact lens Collection offers a wide variety of
Lenses covered-in-full contact lenses from today’s top manufacturers,
including CooperVision and Vistakon , in both traditional and
®
®
Specialty Contact Lenses that Plan pays up to $60, you silicone hydrogel materials. The Collection is inclusive of disposable,
are non-collection, including, pay balance minus 15% planned replacement and select torics and multifocals. The
but not limited to, toric, multi- discount , plus $20 copay Collection is updated regularly to reflect industry trends.
1,2
focal and gas permeable lenses 1 Additional discounts not applicable at Walmart or Sam’s Club
2
LENS OPTIONS (add to spectacle lens prices above) locations.
Standard Progressive Lenses $50 2 These discounts are not considered covered benefits under the
Premium Progressive Lenses $90 Plan. This portion of the Plan is not an insurance product. As of
(Varilux , etc.) 4/1/14, some providers in Maryland and Virginia may no longer
®
Ultra Progressive Lenses $140 provide these discounts.
(digital) 3 Please note that some providers have flat fees that are equivalent
Polarized Lenses $75 to these discounts.
High Index Lenses $55 Exclusions
Blended Segment Lenses $20 The following services are excluded from coverage:
Polycarbonate Lenses for No copay 1. Diagnostic services, except as listed in What’s Covered under the Evidence
of Coverage.
children, monocular and high 2. Medical care or surgery. Covered services related to medical conditions of
prescription the eye may be covered under the Evidence of Coverage.
Polycarbonate Lenses for all $30 3. Prescription drugs obtained and self-administered by the Member for
outpatient use unless the prescription drug is specifically covered under the
other patients Evidence of Coverage or a rider or endorsement purchased by your Group
Transition Lenses $65 and attached to the Evidence of Coverage.
Intermediate Vision Lenses $30 4. Services or supplies not specifically approved by the Vision Care Designee
where required in What’s Covered under the Evidence of Coverage.
Photochromic Lenses $20 5. Orthoptics, vision training and low vision aids.
Scratch-Resistant Coating $20 6. Replacement, within the same benefit period of frames, lenses or contact
lenses that were lost.
Standard Anti-Reflective (AR) $35 7. Non-prescription glasses, sunglasses or contact lenses.
Coating 8. Vision Care services for cosmetic use.
Premium AR Coating $48 Benefits issued under policy form numbers: Non-rider/Freestanding:
Ultra AR Coating $60 MD CFMI: CFMI/51+/GC (R. 7/10) • CFMI/EOC/D-V (R. 10/11) • CFMI/VISION
DOCS (R. 10/11) • CFMI/VISION SOB (R. 10/11) • CFMI/ELIG/D-V (7/09) • and any
Ultraviolet (UV) Coating $12 amendments.
Tinting No copay MD GHMSI: MD/CF/GC (R. 7/10) • MD/CF/EOC/D-V (R. 10/11) • MD/CF/
Plastic Photosensitive Lenses $65 DOCS-V (R. 10/11) • MD/CF/SOB-V (R. 10/11) • MD/CF/ELIG (R. 1/08) • and any
amendments.
Oversized Lenses No copay Ridered: CFMI/VISION RIDER (10/11) • MD/BCOO/VISION (R. 10/11) • MD/CF/
VISION (R. 10/11).
CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc.
CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., and CareFirst BlueChoice, Inc. are independent licensees of the Blue Cross
and Blue Shield Association. The Blue Cross and Blue Shield Names and Symbols are registered trademarks of the Blue Cross and Blue Shield Association.
SUM1723-1P (9/17) ■ 12/12/24 – $10 Copay ■ BlueVision Plus ■ Option B