Vision Coverage

BENEFIT	IN NETWORK	OUT-OF-NETWORK REIMBURSEMENT 1
FREQUENCY
Eye examination (including dilation, as professionally indicated)	Once every calendar year
Eyeglass lenses	Once every calendar year under age 19/Once every two calendar years 19 or older
Frames	Once every two calendar years
Contact lenses (in lieu of eyeglass lenses)	Once every calendar year under age 19/Once every two calendar years 19 or older
EYE EXAMINATION
including dilation as professionally indicated	$15 copayment	Up to $40 allowance
FRAMES
Fashion level frames from “The Collection”	Covered In Full
Designer level frames from “The Collection”	$20 copayment
Premier level frames from “The Collection”	$40 copayment
Retail allowance towards a provider’s frame	Up to $60 allowance	Up to $30 allowance
STANDARD EYEGLASS LENSES 2 (per pair)
Single vision	Covered In Full	Up to $35 allowance
Bifocal	Covered In Full	Up to $40 allowance
Trifocal	Covered In Full	Up to $50 allowance
Lenticular	Covered In Full	Up to $72 allowance
OPTIONAL EYEGLASS LENSES (per pair)	Member Cost
Standard progressive lenses 3	$50 discounted price	Not Covered
Premium progressive lenses 3	$90 discounted price	Not Covered
Glass Grey #3 prescription sunglasses	$11 discounted price	Not Covered
Polycarbonate lenses
Adult 4	$30 discounted price	Not Covered
Dependent Children
Single vision Polycarbonate lenses (in lieu of single vision lenses)	Covered In Full	Not Covered
Bifocal Polycarbonate lenses (in lieu of bifocal lenses)	Covered In Full	Not Covered
Trifocal Polycarbonate lenses (in lieu of trifocal lenses)	Covered In Full	Not Covered
Blended segment lenses	$20 discounted price	Not Covered
Intermediate vision lenses	$30 discounted price	Not Covered
Glass photochromic lenses	$20 discounted price	Not Covered
Plastic photosensitive lenses	$65 discounted price	Not Covered
High-index (thinner and lighter) lenses	$55 discounted price	Not Covered
Polarized lenses	$75 discounted price	Not Covered
OPTIONAL EYEGLASS LENS COATINGS/TREATMENTS	Member Cost
Fashion, sun or gradient tinted plastic lenses	$11 discounted price	Not Covered
Ultraviolet coating	$12 discounted price	Not Covered
Scratch-resistant coating	$20 discounted price	Not Covered
Standard ARC (anti-reflective coating)	$35 discounted price	Not Covered
Premium ARC (anti-reflective coating)	$48 discounted price	Not Covered
Ultra ARC (anti-reflective coating)	$60 discounted price	Not Covered
CONTACT LENSES 5 (in lieu of eyeglass lenses – per pair or initial supply of disposable contact lenses)
Contact lens evaluation and fitting Daily Wear	Covered in full when formulary contact lenses are prescribed	Not Covered
Extended Wear	Covered in full when formulary contact lenses are prescribed	Not Covered
	Formulary 6 / Nonforumulary
Standard daily wear contact lenses	Covered In Full/ Up to $90 allowance 7	Up to $90 allowance
Specialty contact lenses	Covered In Full/ Up to $90 allowance 7	Up to $90 allowance
Disposable contact lenses	Covered In Full/ Up to $90 allowance 7	Up to $90 allowance
Medically necessary contact lenses (prior approval required)	Up to $225 allowance
LOW VISION SERVICES
Evaluation – one visit every 5 years (prior approval required)	Up to $300 allowance per visit
Follow-up visits – up to four follow-up visits every 5 years	Up to $100 allowance per visit
Low vision aids	Up to $600 allowance per aid / $1,200 allowance 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 Includes glass, plastic or oversized lenses.
³ 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.
⁴ Discounted member price waived for monocular patients and patients with prescriptions +/- 6.00 diopters or greater.
⁵ 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.
⁶ Disposable contact lens wearers will receive four multi-packs of lenses. Planned replacement contact lens wearers will receive two multi-packs of lenses.
⁷ Reimbursement amount is applied toward the cost of contact lenses. The allowance may or may not apply to the evaluation/fitting.

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) for pre-enrollment information, to find a network provider, ask benefit questions, verify eligibility or request an out-of-network provider reimbursement form.

VALUE-ADDED FEATURES

Replacement contact lens program—Highmark offers a contact lens replacement program to members. Call 1-800-LENS-123 or visit www.LENS123.com with a current prescription.

Information about laser vision correction services—You are entitled to savings of up to 25% off the provider’s charge, or a 5% discount on any advertised special through a network of credentialed physicians affiliated with Eye Centers of Excellence. (Some centers provide a flat fee equating to these discount levels.)

Eyeglass warranty—Highmark provides an unconditional breakage warranty to repair or replace plan eyewear manufactured in a Davis Vision laboratory for one year from the initial date of delivery.

Additional spectacle eyewear and disposable contact lens discounts—You are entitled to a 20 % discount on the purchase of additional frames and/or spectacle lenses. Members receive a 10% discount on additional disposable contact lenses.

Frame benefit—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 may visit our Web site, www.highmarkblueshield.com, to locate a provider who offers “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 benefit—Contact lenses may be selected in lieu of eyeglasses. No copayment applies towards the initial supply of formulary contact lenses (many of the most popular standard, soft daily wear; disposable or planned replacement) including fitting/follow-up charges. A program allowance will be applied toward contact lenses from the provider’s own supply (which may or may not include fitting/follow-up charges). Program allowances will be applied for both contact lenses and contact lens fitting/follow-up charges. 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.

Low vision services—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.

Exclusions—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.

Network providers—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 retail locations—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.

Locating a network provider—To find a network provider, go to www.highmarkblueshield.com and click on “find a vision network provider.” Click “OK” to be redirected to the Davis Vision, Inc. Web site. 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.

Receiving services from a network provider:—(1) Call the network provider of your choice and schedule an appointment. (2) Identify yourself as a Highmark member, or eligible dependent, in a vision plan administered by Davis Vision. (3) 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. The provider’s office will verify your eligibility for services.

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