Page 10 - 2015 New Hire Guide

Open
Enrollment

Vision

Eye care coverage is available to If you choose a non-network provider, you will need to send
eligible employees of Fontbonne your reimbursement form, itemized receipts, plan participant’s
University through DeltaVision, a Social Security Number and the plan participant’s date of birth
company that offers a network of to DeltaVision. You may obtain a claim form by logging on to
providers who offer affordable, www. deltavisionmo.com.
quality vision care coverage.
NOTE—Vision beneit deductions are taken on a pre-tax basis.
Using Your Vision Benefits Vision Contributions—Monthly
Employee Only $6 .98
DeltaVision’s network includes Employee + Spouse $13 .94

retail and private practice doctors Employee + Child(ren) $14 .78
conveniently located in retail, Family $23 .26
community and professional settings.
Simply present your ID card to the DeltaVision
provider to receive beneits. In-Network Out-of-Network
Vision Exam
$10 copay Reimbursed up to $40*
Lenses
Single $15 copay Reimbursed up to $20 *
Bifocal $15 copay Reimbursed up to $40 *
Trifocal $15 copay Reimbursed up to $60 *
Lenticular $15 copay Reimbursed up to $100 *
Frames
$15 copay** Reimbursed up to $60 *
Contacts
Exam $40 allowance No reimbursement
Elective $150 allowance Reimbursed up to $80

Medically Required $250 allowance* $250 allowance
Frequency
Exam Once every 12 months
Lenses Once every 12 months
Contacts Once every 12 months
Frame Once every 24 months

* Less applicable copay
** No copay if included with lenses . Paid in full on special frame selection . Allowance of $150
if outside the selection .

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