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Finding In-Network VISION
Providers We partner with NVA to offer you and your family members vision
Remember to visit in-network insurance. Visit www.e-nva.com to ind in-network providers and access
provider to receive the deepest to a variety of online tools and programs.
level of discount on your services.
In-Network Out-of-Network
To ind a participating in- Copay
network dentist in your area,
go to www.e-nva.com or Exam Covered 100% Up to $35
call 800.672.7723 . Materials $10 Copay
Lenses
Vision Contributions Single Covered 100% after $25 Up to $25
copay
Bifocal
Up to $45
Vision Trifocal Up to $75
Pre-Tax Weekly
Contributions Lenticular Up to $75
Basic Frames
Employee $1 .14 Covered up to $130 (20% Up to $45
Employee/Spouse $2.28 discount of remaining
Employee/ $3 .65 balance over $130
Child(ren) allowance)
Family $4 .22 Contacts
(in Lieu of Lenses)
Elective $130 allowance, plus Up to $98
10-15% discount over
allowance
Medically Necesasary Covered 100% Up to $210
Contact Lense Fit/Follow-Up
Standard Daily Wear Covered 100% after $20 Up to $20
copay
Standard Extended Wear Covered 100% after $30 Up to $30
Specialty Wear copay
Specialty Wear Covered 100% after $50 Up to $50
copay
Frequency
Exam 12 months
Lenses 12 months
Contacts (in lieu of 12 months
glasses)
Frames 24 months
* You are eligible for your next visit/materials, 12/24 months following your previous exam.
This is a high level summary of your beneit coverage. Full coverage details are available in your
summary plan description (SPD). In the event there is a discrepancy between what is relected in
this guide and what is communicated in your SPD, the terms of your SPD will prevail.
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Providers We partner with NVA to offer you and your family members vision
Remember to visit in-network insurance. Visit www.e-nva.com to ind in-network providers and access
provider to receive the deepest to a variety of online tools and programs.
level of discount on your services.
In-Network Out-of-Network
To ind a participating in- Copay
network dentist in your area,
go to www.e-nva.com or Exam Covered 100% Up to $35
call 800.672.7723 . Materials $10 Copay
Lenses
Vision Contributions Single Covered 100% after $25 Up to $25
copay
Bifocal
Up to $45
Vision Trifocal Up to $75
Pre-Tax Weekly
Contributions Lenticular Up to $75
Basic Frames
Employee $1 .14 Covered up to $130 (20% Up to $45
Employee/Spouse $2.28 discount of remaining
Employee/ $3 .65 balance over $130
Child(ren) allowance)
Family $4 .22 Contacts
(in Lieu of Lenses)
Elective $130 allowance, plus Up to $98
10-15% discount over
allowance
Medically Necesasary Covered 100% Up to $210
Contact Lense Fit/Follow-Up
Standard Daily Wear Covered 100% after $20 Up to $20
copay
Standard Extended Wear Covered 100% after $30 Up to $30
Specialty Wear copay
Specialty Wear Covered 100% after $50 Up to $50
copay
Frequency
Exam 12 months
Lenses 12 months
Contacts (in lieu of 12 months
glasses)
Frames 24 months
* You are eligible for your next visit/materials, 12/24 months following your previous exam.
This is a high level summary of your beneit coverage. Full coverage details are available in your
summary plan description (SPD). In the event there is a discrepancy between what is relected in
this guide and what is communicated in your SPD, the terms of your SPD will prevail.
12
