HDIS 2015 Benefits Guide1

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Home Delivery Incontinent Supply Co.
13
VISION INSURANCE
Our Vision benefit is provided by VBA. If
you utilize an out-of-network provider, your
benefit is based on a reimbursement
schedule. Also, if you are considering
Lasik surgery, there is a discount available.
You can review a full list of providers at
Vision Benefits of American (VBA) Vision
Benefit/Service In-Network
Out-of-Network
Benefit
Examination $20 Co-pay $40 reimbursement
Frequency of Service:
Exam Every 12 months
Lenses Every 12 months
Frames Every 24 months
Lenses: $25 Co-pay then: Reimbursement:
Single 100%* $40
Bifocal 100%* $60
Trifocal 100%* $80
Lenticular 100%* $120
Frames
Covered 100% up to
$125-150 Retail
$65
Contacts: Reimbursement
Necessary UCR $320
Cosmetic $160 Allowance $160
*covered within allowance
2015—2016 Employee Vision
Contributions
Employee Deduction
(per pay Period)
Employee $1.74
Employee & Spouse $3.81
Employee & Child(ren) $3.92
Family $6.14