Page 59 - Takoma Park Benefits Guide 2022

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 Avēsis for reimbursement.
Reimbursement levels are in accordance with the out-of-network reimbursement schedule previously listed. Out-of-network benef ts are subject to
the same eligibility, availability, frequency of benef ts, and limitation and exclusion provisions of the plan; and are in lieu of services provided by a
participating Avēsis provider. Out-of-network claim forms can be obtained by contacting Avēsis’ Customer Service Center, your group administrator or by
visiting www.avesis.com.

Limitations and Exclusions

Some provisions, benef ts, exclusions or limitations listed herein may vary depending on your state of residence.
Limitations:
This plan is designed to cover eye examinations and provide discounts for member’s.

Exclusions:
There are no benef ts under the plan for professional services or materials connected with and arising from:
1) Orthoptics or vision training, subnormal vision aids;
2) Any supplemental testing, aniseikonic lenses;
3) Any medical or surgical treatment of eye or supporting structures;
4) Any eye examination or corrective eyewear required by an employer as a condition of employment and safety eyewear;
5) 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;
6) Any vision materials;
7) Services or materials provided by any other group benef t plan providing vision care.

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.

Notes and Disclaimers

Refractive Laser Surgery is considered Refractive Surgery, an elective procedure, and may involve potential risks to patients. Avēsis is not responsible
for the outcome of any refractive surgery.

Insured benef ts are administered by Avēsis Third Party Administrators, Inc., Phoenix, AZ