Eective Date:
An In-Depth Look
Here’s How It Works
Select a
provider
Make an
appointment
Visit provider
for service
Pay any copays
or additional
expenses
1 2 3 4
When you need to see an eye care professional, simply visit www.avesis.com or contact Avēsis’ Customer Service
Monday through Friday, 7 a.m. to 8 p.m. (EST) at 800-828-9341 to receive a listing of providers in your area.
How can we
help you?
Avēsis Website:
www.avesis.com
Customer Service:
800-828-9341
7 a.m. - 8 a.m. EST
LASIK Provider:
877-712-2010
Vision Care Services In-Network Member Benefits
Out-of-Network
Reimbursement
Materials:
Frame Allowance*
Members receive a wholesale allowance
retail value
Up to
Standard Spectacle Lenses
Single Vision
Bifocal
Trifocal
Lenticular
Covered in full after materials copay
Covered in full after materials copay
Covered in full after materials copay
Covered in full after materials copay
Up to
Up to
Up to
Up to
Other Lens Options
Contact Lenses
(in lieu of frame and spectacle lenses)
Elective
Medically Necessary
Covered in full
Refractive Laser Surgery
Provider discount up to 25%
Frequency
Lenses or contact lenses
Once every
Once every
Frame
Once every
Once every
Group Number:
Plan Number:
Reliable &
Dependable
Avēsis is a national leader in
providing exceptional vision
care benefits for millions
of commercial members
throughout the country.
The Avēsis vision care
products give our members
an easy-to-use wellness
benefit that provides
excellent value
and protection.
Discounts are not insured benets
(Materials copay applies to frame or spectacle lenses, if applicable.)
§
Prior authorization is required for medically necessary contacts.
*
§
1/1/2020
60790-1608
986
City of Marshalltown
$15 copayment
$50
Up to $150
$45.00
$25.00
$40.00
$50.00
$80.00
Standard Progressives
up to $40.00
Employee Paid Rates
Per Month
Employee
$7.16
Employee + Spouse
$13.52
Employee + Child(ren)
$14.74
Employee + Family
$18.96
Lens Options are discounted up to
20% off retail
$130 allowance
$130.00
$250.00
Underwritten by: Fidelity Security Life
Insurance Company, Kansas City,
MO Policy #: VC-16, Form
M-9059
One-time/lifetime allowance of $150
$150.00
12 Months
12 Months
24 Months
24 Months
At participating Walmart locations, retail pricing for your plan is $68. At participating Costco locations, retail pricing is $54.99.
Values provided may be more or less depending on the providers retail pricing.
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 benets are subject to
the same eligibility, availability, frequency of bene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 or your group administrator, or
by visiting www.avesis.com.
Limitations and Exclusions
Some provisions, benets, exclusions, or limitations listed herein may vary depending on your state of residence.
Limitations:
This plan is designed to cover eye examinations and corrective eyewear. It is also designed to cover visual needs rather than cosmetic options. Should
the member select options that are not covered under the plan, as shown in the schedule of benets, the member will pay a discounted fee to the
participating Avēsis provider. Benets are payable only for services received while the group and individual member’s coverage is in force.
Exclusions:
There are no benets under the plan for professional services or materials connected with and arising from:
1) Orthoptics or vision training;
2) Subnormal vision aids and any supplemental testing, aniseikonic lenses;
3) Plano (non-prescription) lenses, sunglasses;
4) Two pair of glasses in lieu of bifocal lenses;
5) Any medical or surgical treatment of eye or supporting structures;
6) Replacement of lost or broken lenses, contact lenses or frames, except when the member is normally eligible for services;
7) Any eye examination or corrective eyewear required by an employer as a condition of employment and safety eyewear;
8) 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;
9) Any vision examination;
10) Services or materials provided by any other group benet plan providing vision care.
Refractive Surgery Vision Benet Exclusions:
Benets are not payable for any of the following:
1) Routine vision examinations or corrective vision materials, including corrective eyeglasses, ttings, lenses, frames, or contact lenses; or
2) Medical or surgical procedures, services, or treatments:
a. not specically covered under this Rider;
b. provided free of charge in the absence of insurance
c. payable under any Workers’ Compensation law or similar statutory authority
d. payable under governmental plan or program, whether Federal, state, or subdivisions thereof.
Notes and Disclaimers
The contact lens allowance may be used all at once or throughout the plan year as needed or may be applied toward contact lenses only, or both contact
lenses and professional services (tting fees). Refractive Laser Surgery is considered an elective procedure, and may involve potential risks to patients.
Avēsis is not responsible for the outcome of any refractive surgery.
Insured benets are administered by Avēsis Third Party Administrators, Inc., Phoenix, AZ
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.
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