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P. 11
2017 BENEFITS ENROLLMENT
Vision Insurance
The vision plan provides coverage for you and your eligible dependents for eye examinations, frames, spectacle
lenses, contact lenses, and out-of-network reimbursement.
The vision plan is provided by Davis Vision Beneits and administered by BlueCross BlueShield of Tennessee.
A listing of network providers and retail locations may be accessed at www.davisvision.com, or call 800.999.5431
enter client code 3413.
Vision Benefit Summary
Regional One Health
Davis Vision
Davis Vision Network
PPO Out-of-Network
Copay
Exam $10 copay Up to $40 reimbursement
Lenses
Single $25 copay Up to $40 reimbursement
Bifocal $25 copay Up to $60 reimbursement
Trifocal $25 copay Up to $80 reimbursement
Lenticular $25 copay Up to $100 reimbursement
Frames
Davis collection frames covered in
full ($160 value), any other provider
frames up to $130 allowance and an Up to $50 reimbursement
additional 20% off
Contacts
Collection contacts covered in full, or
non collection contacts covered up Up to $105 reimbursement
to $130 retail allowance plus 15% off
balance
Frequency
Exam 12 months 12 months
Lenses 12 months 12 months
Contacts (In Lieu of Glasses) 12 months 12 months
Frames 24 months 24 months
Bi-Weekly Premium Comparison
Regional One Health
Davis Vision
Davis Vision Network
Employee Only $3 .22
Employee + Spouse $6 .44
Employee + Child(ren) $5 .64
Family $8 .86
Additional coverage information is available to you at http://visityouville.com/ROHBeneits.
REGIONAL ONE HEALTH 11
Vision Insurance
The vision plan provides coverage for you and your eligible dependents for eye examinations, frames, spectacle
lenses, contact lenses, and out-of-network reimbursement.
The vision plan is provided by Davis Vision Beneits and administered by BlueCross BlueShield of Tennessee.
A listing of network providers and retail locations may be accessed at www.davisvision.com, or call 800.999.5431
enter client code 3413.
Vision Benefit Summary
Regional One Health
Davis Vision
Davis Vision Network
PPO Out-of-Network
Copay
Exam $10 copay Up to $40 reimbursement
Lenses
Single $25 copay Up to $40 reimbursement
Bifocal $25 copay Up to $60 reimbursement
Trifocal $25 copay Up to $80 reimbursement
Lenticular $25 copay Up to $100 reimbursement
Frames
Davis collection frames covered in
full ($160 value), any other provider
frames up to $130 allowance and an Up to $50 reimbursement
additional 20% off
Contacts
Collection contacts covered in full, or
non collection contacts covered up Up to $105 reimbursement
to $130 retail allowance plus 15% off
balance
Frequency
Exam 12 months 12 months
Lenses 12 months 12 months
Contacts (In Lieu of Glasses) 12 months 12 months
Frames 24 months 24 months
Bi-Weekly Premium Comparison
Regional One Health
Davis Vision
Davis Vision Network
Employee Only $3 .22
Employee + Spouse $6 .44
Employee + Child(ren) $5 .64
Family $8 .86
Additional coverage information is available to you at http://visityouville.com/ROHBeneits.
REGIONAL ONE HEALTH 11
