UPHS_Enrollment_Guide_FINAL

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Print this Guide Human Resources/ Benefits Locations Making Changes During the Year Contact Information Search this Document > Carewise Health Programs Medical Behavioral Health Prescription Drug Vision IBC Davis Vision Premium Plan IBC Davis Vision Standard Plan Vision Benefits of America (VBA) Plan Dental Flexible Spending Accounts (FSAs) Life Insurance AD&D Coverage Disability Legal Notices Welcome What’s New Cost for Coverage Plan Highlights Welcome > Vision > IBC Davis Vision Premium Plan IBC Davis Vision Premium Plan IBC Davis Vision Premium Plan How to Access Care Scheie Provider All Other Participating Providers Non-Participating Providers Eye Exam (once per Covered at 100% Covered after $10 copay Reimbursement of up to $32 contract year) Standard Lenses (once per contract year) Covered at 100% for all ranges of prescriptions Covered at 100% for all ranges of prescriptions Reimbursement of up to: • Single vision: $30 • Bifocal: $36 • Trifocal: $50 • Lenticular: $72 Frames Medically necessary contact lenses (in lieu of eyeglasses) and evaluation and fitting, with prior approval Contact lenses (in lieu of eyeglasses) including standard, specialty and disposable lenses Participating provider's frame collection: • $100 allowance OR • Davis' Fashion selection: 100% • Designer selection: 100% • Premier selection: $20 Participating provider's frame collection: • $65 allowance OR • Davis' Fashion selection: 100% • Designer selection: 100% • Premier selection: $20 Reimbursement of up to $30 Covered up to $200 Covered up to $200 Reimbursement of up to $200 Allowance of up to: • Standard/Specialty: $110 • Disposable: $80 Allowance of up to $75 Reimbursement of up to: • Standard/Specialty: $60 • Disposable: $75 This chart does not provide a complete description of the plans. For more details, please contact the UPHS Benefits Office at 215-615-2277.
Print this Guide Human Resources/ Benefits Locations Making Changes During the Year Contact Information Search this Document > Carewise Health Programs Medical Behavioral Health Prescription Drug Vision IBC Davis Vision Premium Plan IBC Davis Vision Standard Plan Vision Benefits of America (VBA) Plan Dental Flexible Spending Accounts (FSAs) Life Insurance AD&D Coverage Disability Legal Notices Welcome What’s New Cost for Coverage Plan Highlights Welcome > Vision > IBC Davis Vision Standard Plan IBC Davis Vision Standard Plan IBC Davis Vision Standard Plan How to Access Care Participating Providers Non-Participating Providers Eye Exam (once per contract year) Covered after $10 copay Reimbursement of up to $30 Standard Lenses (once per contract year) Frames Medically necessary contact lenses (in lieu of eyeglasses) and evaluation and fitting, with prior approval Contact lenses (in lieu of eyeglasses) including standard, specialty and disposable lenses Covered at 100% for all ranges of prescriptions Participating provider's frame collection: • Single vision: $20 • Bifocal: $20 • Trifocal: $30 • Lenticular: $50 Participating provider's frame collection: Reimbursement of up to $15 • $15 allowance OR • Davis' Fashion selection: 100% • Designer selection: $16 • Premier selection: $35 Allowance of up to $100 Reimbursement of up to $200 Not Covered This chart does not provide a complete description of the plans. For more details, please contact the UPHS Benefits Office at 215-615-2277. Not Covered
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UPHS_Enrollment_Guide_FINAL

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