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NYE COUNTY Eye Care Highlight Sheet Plan 1: Focus® Plan Summary VSP Network Out of Network Deductibles $10 Exam $10 Exam $0 Eye Glass Lenses or Frames* $0 Eye Glass Lenses or Frames Annual Eye Exam Covered in full Up to $52 Lenses (per pair) Single Vision Covered in full Up to $55 Bifocal Covered in full Up to $75 Trifocal Covered in full Up to $95 Lenticular Covered in full Up to $125 Progressive See lens options NA Contacts Fit & Follow Up Exams 15% discount No benefit See Additional Focus Features. Elective Up to $105 Up to $105 Medically Necessary Covered in full Up to $210 Frames $120 Up to $45 Frequencies (months) Exam/Lens/Frame 12/12/24 12/12/24 Based on date of service Based on date of service *Deductible applies to a complete pair of glasses or to frames, whichever is selected. Lens Options (member cost)* VSP Network Out of Network Progressive Lenses Up to provider's contracted fee for Lined Trifocal Lenses. The patient is responsible for the difference between the base lens and the Progressive Lens charge. Up to Lined Trifocal allowance. Std. Polycarbonate Covered in full for dependent children $25 adults No benefit Solid Plastic Dye $13 (except Pink I & II) No benefit Plastic Gradient Dye $15 No benefit Photochromatic Lenses (Glass & Plastic) $27-$76 No benefit Scratch Resistant Coating $15-$29 No benefit Anti-Reflective Coating $39-$75 No benefit Ultraviolet Coating $14 No benefit *Lens Option member costs vary by prescription, option chosen and retail locations. ---PAGE BREAK--- NYE COUNTY Eye Care Highlight Sheet Additional Focus® Features Contact Lenses Elective Allowance can be applied to disposables, but the dollar amount must be used all at once (provider will order 3 or 6 month supply). Applies when contacts are chosen in lieu of glasses. For plans without a separate contact lens fit & follow up exam allowance, the cost of the fitting and evaluation is deducted from the contact allowance. Additional Glasses 20% discount off the retail price on additional pairs of prescription glasses (complete pair). Frame Discount VSP offers a 20% discount off the remaining balance in excess of the frame allowance. Laser VisionCare VSP offers an average discount of 15% on LASIK and PRK. The maximum out-of-pocket per eye for members is $1,800 for LASIK and $2,300 for custom LASIK using Wavefront technology, and $1,500 for PRK. In order to receive the benefit, a VSP provider must coordinate the procedure. Low Vision With prior authorization, 75% of approved amount (up to $1,000 is covered every two years). Rx Savings Our valued plan members and their covered dependents (even their pets) can save on prescription medications through any Walmart or Sam's Club pharmacy across the nation. This Rx discount is offered at no additional cost, and it is not insurance. To receive the Walmart Rx discount, Ameritas plan members just need to visit us at ameritas.com and sign into (or create) a secure member account where they can access and print an online-only Rx discount savings ID card. Eye Care Plan Member Service Focus eye care from Ameritas Group features the money-saving eye care network of VSP. Customer service is available to plan members through VSP's well-trained and helpful service representatives. Call or go online to locate the nearest VSP network provider, view plan benefit information and more. VSP Call Center: 1-[PHONE REDACTED] Service representative hours: 5 a.m. to 7 p.m. PST Monday through Friday, 6 a.m. to 2:30 p.m. PST Saturday Interactive Voice Response available 24/7 Locate a VSP provider at: ameritas.com/member View plan benefit information at: vsp.com Section 125 This plan is provided as part of the Policyholder's Section 125 Plan. Each employee has the option under the Section 125 Plan of participating or not participating in this plan. If an employee does not elect to participate when initially eligible, he/she may elect to participate at the Policyholder's next Annual Election Period. Worldwide Support When our members travel abroad, they’ll have peace of mind knowing that should a dental or vision need arise, help is just a phone call away. Through AXA Assistance, Ameritas offers its dental and vision plan members 24-hour access to dental or vision provider referrals when traveling outside the U.S. Immediately after a call is made to AXA, an assistance coordinator assesses the situation, provides credible provider referrals and can even assist with making the appointment. Within 48 hours following the appointment, the coordinator calls the member to find out if additional assistance is needed. If all is well, the case is closed. Then, the plan member may submit a claim to Ameritas for reimbursement consideration based on applicable plan benefits. Contact AXA Assistance USA toll free by calling [PHONE REDACTED], or call collect from anywhere in the world by dialing 1-[PHONE REDACTED]. Language Services We recognize the importance of communicating with our growing number of multilingual customers. That is why we offer a language assistance program that gives you access to: Spanish-speaking claims contact center representatives, telephone interpretation services in a wide range of languages, online dental network provider search in Spanish and a variety of Spanish documents such as enrollment forms, claim forms and certificates of insurance.