Vision Benefits:

  Participating
Provider
Non-Participating
Provider
Comprehensive Examination: Covered Up to $40.00
Single Vision Lenses: Covered Up to $30.00
Bifocal Lenses: Covered Up to $50.00
Trifocal Lenses: Covered | Up to $85.00 Up to $65.00
Polycarbonate Lenses:*** Covered | Up to $85.00 Up to $55.00
Progressive Lenses: Up to $89.50 Up to $65.00
Photochromic Lenses: Up to $30.00 Up to $20.00
Anti-Reflective: Up to $25.00 Up to $15.00
Ultraviolet Coating: Up to $16.00 Up to $10.00
Scratch Coating: Up to $15.00 Up to $5.00
Aphakic Monofocal: Covered Up to $125.00
Aphakic Multifocal: Covered Up to $125.00
Frame Retail Allowance*: Up to $150.00 Up to $75.00
Contact Lenses: **    
Medically Necessary: Covered Up to $250.00
Cosmetic or Convenience: Up to $150.00 Up to $150.00

Summary of Vision Benefits:

Co-pay: $10.00 Exam / $25.00 Materials
Comprehensive Vision Exam: One every 12 months
Lenses/Contact Lenses:** One pair every 12 months
Frame: One frame every 24 months

* Participating Providers allow a selection of frames that retail up to $150.00 with lenses that fit an eyesize less than 61 millimeters.

** This benefit is in addition to the comprehensive vision examination, but in lieu of lenses and frame.

*** For Dependent Children through age 18

LIMITATIONS
Contact Lenses and fitting except as specifically provided; Eyewear when there in no prescription change, except when benefits are otherwise available; Non-standard lenses, including, but not limited to; Progressive, Photochromic, hi-index, Polycarbonate, occupational lenses, beveled, faceted, coated or oversize; Tints other than pink or rose #1 or #2,
except as specifically provided; Two pair of glasses in lieu of bifocals, unless prescribed; New-patient intermediate examinations: .When an Enrollee selects a different provider to perform the intermediate examination , the Enrollee will be responsible for the difference between the intermediate examination allowance and the comprehensive examination allowance. To maximize benefits, the patient should return to the original provider; Non-prescription (Plano) eyewear, except when specifically covered.

EXCLUSIONS
Any eye examination required by the employer as a condition of employment; Any covered services provided by another vision plan; Conditions covered by Workers’ Compensation; Contact lens insurance of care kits; Frame cases; Covered Services which began prior to the Enrollee’s effective date or after benefits have been terminated; Charges for which the Enrollee is not legally obligated to pay; Covered Services required by any government agency or program federal, state or subdivision thereof; Covered Services performed by a Close Relative or by an individual who ordinarily resides in the Enrollee’s home; Covered Services obtained from a Non-Participating Provider; Medical or Surgical treatment of the eyes; Orthoptics, vision training or Subnormal or Low Vision Aids; Services that are Experimental or Investigational in nature; Services for treatment directly related to any totally disabling condition, illness or injury; Lenses or frames which are lost, stolen or broken will not be replaced, except when benefits are otherwise available; In connection with war or any act of war whether declared or undeclared; a condition or accident occurring while on full-time active duty in the armed forces or any country or combination of countries. This is a brief outline of the plan and is not to be accepted or construed as a substitute for the provisions of the contract.

If you have any questions about your vision benefits,
please contact Medical Eye Services at:
PO Box 25209; Santa Ana, CA 92799
800/877-6372 or www.MESVision.com

Underwritten By:
FCL 12/12/24 $150 $150 $10 $25 Co-pay 6/28/2017
Gerber Life Insurance Company
A separate subsidiary of Gerber Products
Home Office: White Plains, NY 10605
Gerber Life Insurance Company
A separate subsidiary of Gerber Products
Home Office: White Plains, NY 10605

You must join AAIC (American Association of Independent Contractors) for $2 a month to get
access to BrightIdea Dental.

Vision plans not available in Maine, Minnesota, New Hampshire, or Washington