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Health Fund

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Vision Benefits

All eligible participants (excluding participants covered under the Low Option Plan) will automatically be enrolled in the new vision program which is administered through Davis Vision.

PPO Plan
  Network
Provider
2
Non-Network Provider 3 Out of Area
(For participants who live over 25 miles outside the PPO service area of 2 providers)3 4
Network
Provider 2
Non-Network Provider 3
Plan Benefits
Eye Examination $10 copay $50 allowance Not applicable Not covered11 Not covered
Eye Glasses
(in lieu of contact lenses)
Each Calendar Year Each Calendar Year
Lenses $25 copay standard single-vision, lined bifocal, or trifocal $50 Single Vision
$65 Bifocal/
Progression
$80 Trifocal
$100 Lenticular
Not applicable Not covered Not covered
Frames 100% - Davis Vision Frames - or -
$130 retail allowance, plus 20% off balance
$70 allowance Not applicable Not covered Not covered
Contact Lenses
(in lieu of eye glasses)
Each Calendar Year Each Calendar Year      
Evaluation, Fitting & Follow-up Care Collection Contacts:
$25 copay

Specialty: $60 allowance with 15% off balance less $25 copay
Elective contacts up to $105
Medical Necessary Contact up to $225
Not applicable Not covered Not covered
Contact Lenses Covered in full
Any contact lenses from Davis Vision's Contact Lens Collections
-OR-
$130 allowance toward provider supplied contact lenses, plus 15% off balance.
Elective contacts up to $105
Medical Necessary Contact up to $225
Not applicable Not covered Not covered


IMPORTANT!
Vision benefits cannot be split between a network and out-of-network provider.
Each calendar year, eye glasses or contact lens are covered under the vision care benefits and not both.
For out-of-network providers you can obtain a claim form from our website at www.wgaplans.org or on-line at www.davisvision.com.
Additional discounts not applicable at Walmart of Sam's Club locations.

2. Benefits for services received from a network provider will be paid based on the contracted rate.

3. Benefits for services received from non-network and out-of-area providers will be paid based on reasonable and customary (R&C) allowances. The participant is responsible for any amount over the R&C.

11. See Preventive Care Benefits Services, page 10. Some or all of the services in this section may be covered under the Preventive Care Service Benefits, payable at 100%, no deductible, when seen by a network provider.