The benefit is available to You and Your dependents. This benefit entitles You and Your family to vision care services if You are eligible pursuant to the requirements of the Plan.

What are the Plan benefits?

Annually (every January 1) You are entitled to:

• a comprehensive eye examination (including dilation), and:
• spectacle lenses, or:
• contact lenses (in lieu of eyeglasses):
• safety eyeglass (in lieu of eyeglasses):

Biannually (every other January 1) You are entitled to:

• an eyeglass frame.

Who are the in-network doctors?

They are licensed doctors who are extensively reviewed and credentialed to ensure that standards for quality service are maintained. Davis Vision’s extensive network of nearly 11,000 doctors nationwide makes it possible for the majority of active and retired Fund Participants to receive services from a doctor in the network. To locate the in-network doctors nearest to You, just call 1- 800-999-5431 or access the Davis Vision website at www.davisvision.com and utilize the “Find a Doctor” feature. Davis Vision Retail’s name changed to Visionworks but, the benefit of Davis Vision will remain the same.

How do I receive services from an in-network doctor?

• Call the in-network doctor of Your choice and schedule an appointment;
• Identify Yourself as a Participant or Dependent of the I.B.E.W. Local 25 Health& Benefit Fund vision plan;
• Provide the office with the Participant’s Identification number and the year of birth of any covered children needing services.

The doctor’s office will verify Your eligibility for services – no claim forms are required.

What types of eyewear may I select?

• any frame from the special Fashion and Designer selections displayed on the “Davis Vision Collection of Frames” in each in-network doctor’s office, or $55 retail credit plus an additional  20% discount off any overage will be applied toward the purchase of a frame from the doctor’s private selection: and
• any spectacle lens type; many are included at no additional cost; or
• contact lenses; in lieu of eyeglasses; standard, soft, daily-wear and disposable/planned replacement; types are available for most prescriptions with a minimal co-payment (see below). A $105.00 credit will be applied toward other types of contact lenses (i.e., toric, gas permeable) from the doctor’s private selection.Please note: contact lenses can be worn by most people, but not by all. Once the contact lens option is selected and the lenses are fitted, they may not be exchanged for eyeglasses.
• safety eyeglasses; in lieu of eyeglasses; choose frames from specified Designer Safety Collection or use your own frame. In-network, a $40 credit will be applied toward a safety frame from the providers selection of safety frames. Out- of Network safety eyewear must be received from an in-network provider. There is no out-of network reimbursement for safety eyewear.

What are my costs for services?

• EYE EXAMINATIONS	Every January 1, including dilation as professionally indicated.
  In-Network Copayment	$10
  Out-of-Network	Reimbursed up to $20

• EYEGLASSES
  Frame	Every other January 1
  Spectacle Lenses	Every January 1
  You may choose any Fashion or Designer level frame from Davis Vision Frame Collection, covered in full. Or, if you select another frame in the network provider’s office, a $55 credit, plus a 20% discount off any overage will be applied. This credit would also apply at retail locations that do not carry the Frame Collection. Members are responsible for the amount over $55 (less the applicable discount).
  Out-of-Network	Reimbursed up to $20 for frames, up to $20 for single vision lenses, up to $30 or bifocals, up to $40 for trifocals.

• CONTACT LENSES	every 12 months
  In-Network Copayment	$35
  In lieu of eyeglasses, you may select contact lenses. Any contact lenses from Davis Vision Contact Lens Collection will be covered in full per the number indicated below, and your evaluation, fitting and follow up care will also be covered.
  Davis Vision Contact Lens Collection (includes evaluation, fitting, follow-up):
  Disposable	Four boxes/multi-packs
  Planned Replacement	Two boxes/multi-packs
  In lieu of the Davis Vision contact lenses, members may use their $105 credit to go toward the provider’s own supply of contact lenses, evaluation, fitting and follow-up care. This credit would also apply towards all contact lenses received at participating retail locations.

What lenses/coatings are included?

• plastic or glass single vision, bifocal or trifocal lenses, in any prescription range
• glass grey #3 prescription lenses
• oversize lenses
• post-cataract (lenticular) lenses
• fashion, sun or gradient tinted plastic lenses
• polycarbonate lenses (for dependent children and monocular patients)

Are there any optional frames, lenses or lens coatings available?

Yes, You can pay the low, discounted fixed fees indicated and receive these optional items:

	Dress	Safety
Premier Frame	$20	$20
Anti-relective coating
Standard	$35	$35
Premium	$48	$48
Ultra	$60	N/A
Glass photochromic lenses	Included	N/A
Blended invisible bifocals	Included	Included
Double segment lenses	N/A	$60
Plastic Photosensitive lenses	$40	$40
High-Index lenses	$55	$55
Scratch-Resistant coating	Included	Included
Ultraviolet (UV) coating	$12	$12
Intermediate-Vision lenses	$30	$30
Polycarbonate lenses (adult)	$30	$30
Polarized lenses	$75	$75
Progressive addition multifocal lenses.***
Standard types	$50	$50
Premium	$90	$90

** These lens are options and copays apply to in-network benefits only.

***Progessive addition multifocals can be worn by most people. Conventional bifocals will be supplied at no additional cost for anyone who is unable to adapt to  progressive addition lenses, however, the copayment is not refundable.

More special features:

• membership and access to a mail order replacement contact lens service, Lens 1-2-3, providing a fast and convenient way to purchase replacement contact lenses at significant savings. Call 1-800-LENS-123 (1-800-536-7123) for more information
• a one year unconditional breakage warranty is provided for all eyeglasses completely supplied by Davis Vision

What about out-of-network provider benefits?

You may receive services from an out-of-network provider; however, You will receive the greatest value and maximize Your benefit dollars if You select an In-network doctor.

If You choose an out-of-network provider, You must:

• pay the provider directly for all charges
• submit Your claim for reimbursement to:Vision Care Processing Unit
  P.O. Box 1525
  Latham, New York 12110

Services will be reimbursed up to the following:

eye examinations	$20.00
single vision lenses	$20.00 (per pair)
bifocal lenses	$30.00 (per pair)
trifocal lenses	$40.00 (per pair)
a frame	$20.00
contact lenses	$105.00

Claim forms are available by calling: 1-800-999-5431

Remember, You can claim reimbursement for an eye examination and lenses (if Your prescription has changed) every January 1, but only claim reimbursement for a frame every other January 1.

May I use the benefit at different times?

All available services must be obtained at one time from either one in-network or one out-of-network location.

EXCLUSIONS – VISION

The following items are not covered by this vision program:

• medical treatment of eye disease or injury
• visual therapy
• special lens designs or coatings, other than those previously described
• replacement of lost eyewear
• non-prescription (plano) lenses
• two pair of eyeglasses in lieu of bifocals
• contact lenses and a frame in the same 12-month period
• services not performed by licensed personnel

Need more information? Please feel free to call Davis Vision at 1-800-999-5431 to:

• locate an in-network doctor in Your area
• verify eligibility for Yourself or a family member
• request an out-of-network provider reimbursement claim form
• speak with a Participant Service Representative
• ask any questions about Your vision benefits

Participant Service Representatives are available:

• Monday through Friday, 8:00 A.M. to 11:00 P.M., Eastern Time, and
• Saturday, 9:00 AM. to 4:00 P.M., Eastern Time
• Sunday, 12:00 P.M. to 4:00 P.M., Eastern Time

T.D.D. (Telephone Device for the Deaf) services are available by calling: 1-800-523-2847