UPHS_Enrollment_Flipbook_Print_Version

IBC Davis Vision Premium PlanHow to Access Care Scheie Provider All Other Participating Non-ParticipatingProvidersProvidersFramesMedically necessarycontact lenses (in lieuof eyeglasses) andevaluation and fitting,with prior approvalContact lenses (in lieuof eyeglasses)including standard,specialty anddisposable lensesParticipating provider'sframe collection:• $100 allowanceOR• Davis' Fashionselection: 100%• Designer selection:100%• Premier selection: $20Participating provider'sframe collection: $65 allowanceOR Davis' Fashionselection: 100% Designer selection:100% Premier selection: $20Reimbursement of up to $30Covered up to $200 Covered up to $200 Reimbursement of up to$200Allowance of up to:• Standard/Specialty:$110• Disposable: $80IBC Davis Vision Standard PlanAllowance of up to $75Reimbursement of up to:• Standard/Specialty: $60• Disposable: $75IBC Davis Vision Standard PlanHow to Access Care Participating Providers Non-Participating ProvidersEye Exam (once per contract year) Covered after $10 copay Reimbursement of up to $30Standard Lenses (once percontract year)FramesMedically necessary contactlenses (in lieu of eyeglasses) andevaluation and fitting, with priorapprovalContact lenses (in lieu ofeyeglasses) including standard,specialty and disposable lensesCovered at 100% for all ranges ofprescriptionsParticipating provider's frame collection:• $15 allowanceOR• Davis' Fashion selection: 100%• Designer selection: $16• Premier selection: $35Participating provider's framecollection:• Single vision: $20• Bifocal: $20• Trifocal: $30• Lenticular: $50Reimbursement of up to $15Allowance of up to $100 Reimbursement of up to $200Not CoveredNot Covered15