Vision Benefit Schedule | Penn State Student Affairs

Summary of Fashion Focus Option V Benefits

Benefit	Network	Out-Of-Network Reimbursment¹
Frequency²
Eye examination (including dilation, as professionally indicated)	Once every 12 months	Once every 12 months
Eyeglass Lenses	Once every 12 months	Once every 12 months
Frames	Once every 12 months	Once every 12 months
Contact lenses (in lieu of eyeglass lenses)	Once every 12 months	Once every 12 months
Eye Examination
Eye Examination (including dilation as professionally indicated)	Covered In Full	Plan pays up to $40
Frames³
Fashion level frames from "The Collection"	Covered In Full
Designer level frames from "The Collection"	Member pays $20
Premier level frames from "The Collection"	Member pays $40
Retail allowance towards a provider's frame	Plan pays up to $60	Plan pays up to $30
Retail allowance towards a frame from VisionWorks	Plan pays up to $110	Plan pays up to $30
Standard Eyeglass Lenses³ (per pair)⁴
Single vision	Covered In Full	Plan pays up to $35
Bifocal	Covered In Full	Plan pays up to $40
Trifocal	Covered In Full	Plan pays up to $45
Lenticular	Covered In Full	Plan pays up to $50
Optional Eyeglass Lenses (per pair)
Standard progressive lenses ⁵	Member pays $50	Not Covered
Premium progressive lenses ⁵	Member pays $90	Not Covered
Glass Grey #3 prescription sunglasses	Member pays $11	Not Covered
Adult ⁶ - Polycarbonate lenses	Member pays $30	Not Covered
Dependent children Single vision Polycarbonate lenses (in lieu of single vision eyeglass lenses)	Covered In Full	Not Covered
Dependent children Bifocal Polycarbonate lenses (in lieu of bifocal eyeglass lenses)	Covered In Full	Not Covered
Dependent children Trifocal Polycarbonate lenses (in lieu of trifocal eyeglass lenses)	Covered In Full	Not Covered
Blended segment lenses	Member pays $20	Not Covered
Intermediate vision lenses	Member pays $30	Not Covered
Glass photochromic lenses	Member pays $20	Not Covered
Plastic photosensitive lenses	Member pays $65	Not Covered
High-index (thinner and lighter) lenses	Member pays $55	Not Covered
Polarized lenses	Member pays $75	Not Covered
Optional Eyeglass Lens Coatings/Treatments
Fashion, sun or gradient tinted plastic lenses	Member pays $11	Not Covered
Ultraviolet Coating	Member pays $12	Not Covered
Scratch-resistant coating	Covered In Full	Not Covered
Standard ARC (anti-reflective coating)	Member pays $35	Not Covered
Premium ARC (anti-reflective coating)	Member pays $48	Not Covered
Ultra ARC (anti-reflective coating)	Member pays $60	Not Covered
Contact Lenses⁷ (in lieu of eyeglass lenses—per pair or initial supply of disposable contact lenses)
Contact lens evaluation and fitting - Daily wear	Covered In Full	Plan pays up to $20
Contact lens evaluation and fitting - Extended wear	Covered In Full	Plan pays up to $30
Standard daily wear contact lenses	Covered In Full	Plan pays up to $48
Specialty contact lenses	Member pays up to $160	Plan pays up to $50
Disposable contact lenses	Member pays up to $160	Plan pays up to $50
Medically necessary contact lenses (prior approval required)	Covered In Full	Plan pays up to $225
Low Vision Services
Evaluation – one visit every 5 years (prior approval required)	Plan pays up to $300 per visit
Follow-up visits—up to four follow-up visits every 5 years	Plan pays up to $100 per visit
Low vision aids	Plan pays up to $600 per aid $1,200 lifetime maximum

¹ If you choose an out-of-network provider, you must pay the provider directly for all charges and then submit a claim for reimbursement.

² Eligibility will be determined from the date of the last similar service paid under this program, or any other Highmark vision program for this group.

³ Safety glasses are eligible in lieu of Dress frames and Dress lenses for the employee only.

⁴ Includes glass, plastic or oversized lenses. Includes safety glasses.

⁵ Progressive multifocals can be worn by most people. Conventional bifocals will be supplied at no additional charge for anyone who is unable to adapt to progressive lenses. However, the discounted price will not be refunded.

⁶ Discounted member price waived for monocular patients and patients with prescriptions +/- 6.00 diopters or greater.

⁷ Contact lenses can be worn by most people. Once the contact lens option is selected and the lenses fitted, they may not be exchanged for eyeglasses.

: The Davis Vision provider network is being used through a contractual arrangement between Davis Vision and Highmark. Davis Vision is an independent company that manages a network of licensed vision providers in both private practice and retail locations. Network providers are reviewed and credentialed to ensure that standards for quality and service are maintained.

: In order to provide you with the greatest amount of flexibility and convenience, the network includes a number of retail establishments. Benefits at the retail locations may vary slightly from other locations, as noted in this benefit description. However, your value is comparable.

: To find a network provider, go to www.highmarkblueshield.com and click on “Find a Doctor or Rx.” Click on “Find an Eyecare Provider”. Enter your zip code and mile radius then click on “Search” to see the most current listing of providers that will accept your vision plan

: Click here to view locations.

Call the network provider of your choice and schedule an appointment.
Identify yourself as a Highmark member, or eligible dependent, in a vision plan administered by Davis Vision.
Provide the office with your identification (ID) number (located on your Highmark ID card), and the name and birth date of the covered dependent receiving services.

It's that easy! The provider's office will verify your eligibility for services. No claim forms are required.

Select a Participating Vision Provider
1. Customer Service 1-800-223-4795
2. Website www.highmarkblueshield.com
3. Email BlueVisionAdmin@highmark.com
Call Provider to schedule an appointment
1. Identify yourself as a Highmark member
2. Provide your name and ID from your ID Card
Provider can verify your eligibility online
Services are Rendered/Ordered by the Provider
1. 1. Network providers take care of all paperwork
  2. If you need to file a claim, mail to:

Davis Vision

P.O Box 1525

Latham, NY 12110

5. Eyeglasses/contact lenses are made at Davis Lab

6. Eyewear is shipped to the provider

7. Return to the provider's office for dispensing and fitting

When a vision service is rendered outside of the country, please follow the steps below:

Schedule an appointment with the provider of your choice.
Once the services have been rendered, you will need to pay the provider in full.
Mail the completed claim form*, along with a copy of your itemized receipt to:

Davis Vision

P.O Box 1525

Latham, NY 12110

*Claim forms are available from the Highmark website

4. Services rendered outside of the country are considered out-of-network; therefore, payment will be issued directly to you based upon the benefit allowance.

: You may choose from 'The Collection' in most independent network provider offices or a program allowance will be applied toward a network provider's own frames. Many Collection frames are covered in full or have a nominal copayment which helps you select high-quality frames while minimizing out-of-pocket expenses. Network retail providers typically do not display the Collection. You will instead be given a program allowance toward your frame purchase. If the chosen frame exceeds the allowance, you will be responsible for any remaining balance.

: Contact lenses may be selected in lieu of eyeglass lenses. A program allowance will be applied toward contact lenses from the provider's own supply. At a network retail location, you will receive an allowance toward the cost of lenses from the retailer’s supply. With prior approval, medically necessary contact lenses will be covered in full at all network provider locations.

: You and your covered dependents are entitled to a comprehensive low vision evaluation once every five years and low vision aids up to the plan maximum. Up to four follow-up visits will be covered during the five-year period.

: This vision program excludes coverage for certain items and services, including: medical treatment of eye disease or injury; vision therapy; special lens designs or coatings other than those previously described; replacement of lost or stolen eyewear; non-prescription (Plano) lenses; and services not performed by licensed personnel.

Value-Added Features

: All eyeglasses come with a breakage warranty for repair or replacement of the frame and/or lenses for a period of one year from the date of delivery. The one-year breakage warranty applies to all plan-covered eyeglasses (i.e. all spectacle lenses. Davis Vision Exclusive Collection frames and national retailer frames, where our Exclusive Collection is not displayed).

: Highmark members will receive 50% off of additional complete pairs of eyeglasses and sunglasses at Visionworks and 30% off at other participating providers on the same transaction. Otherwise, a 20% discount off the providers usual and customary rate is available at a 10% discount.

: Standard scratch-resisting coating is available for plastic lenses free of charge. Members may also purchase an optional scratch protection plan, which will replace scratched lenses with new lenses of the same material, style, and prescription, at no charge for one year from the original date of dispensing.

: Highmark offers a contact lens replacement program to members. This mail order program exclusively allows you to enjoy the guaranteed lowest prices on contact lens replacement materials. Call 1-855-589-7911 or visit www.davisvisioncontacts.com with a current prescription. Every order comes with a complimentary starter kit.

: Highmark members enjoy lower prices on LASIK procedures than other carriers, along with flexible financing options – up to 12 months interest-free. These savings are up to 40%-50% off the national average price of traditional LASIK and are available at over 1,000 locations across our nationwide network of laser vision correction providers. Laser vision correction services are administered by QualSight, LLC. Terms and conditions are subject to change.

Laser vision correction services are administered by QualSight, LLC. Terms and conditions are subject to change.

: Highmark members can receive a retinal imaging exam at participating providers at a discounted fee. The exam enables the retina, macula, blood vessels, and optic nerve to be seen in a wide angle, digital images without the use of dilation drops. The exam is brief and very comfortable and allows for early detection, diagnosis, and ongoing monitoring of diseases which can affect the eyes and overall health.

: Auditory health and wellness are increasingly important with hearing loss on the rise. Our members have free access to EPIC Hearing Service Plans for a savings of up to 30%-60% off of suggested retail prices for brand name hearing aids through the largest, accredited network of audiologists and ENT physicians. Additional savings are available through EPIC's "Listen Hear, Live Well" rewards program. Call EPIC today at 1-844-246-0544 to start the process to better hearing.

Contact

Call Member Service Monday through Friday, 8:00 am to 5:00 pm, Eastern Standard Time (EST) at 1-800-223-4795 (TTY users call 1-800-523-2847) to find a network provider, ask benefit questions, verify eligibility or request an out-of-network provider reimbursement form. For information prior to enrolling, call 1-800-223-4795