Blue View Vision Plan Benefit Summary

Blue View Vision (SM) Iona University
Plan BV C 10.0 130/130

Welcome to your Blue View Vision plan!

You have many choices when it comes to using your benefits. As a Blue View Vision plan member, you have access to one of the nation’s largest vision networks.

You may choose from many private practice doctors, local optical stores, and national retail stores including LensCrafters®, Target Optical®, Sears Optical®, JCPenney® Optical and most Pearle Vision® locations. You may also use your in-network benefits to order eyewear online at Glasses.com and ContactsDirect.com.

To locate a participating network eye care doctor or location, log in at empireblue.com, or from the home page menu under Care, select Find a Doctor. You may also call member services for assistance at (866) 723-0515.

Plan Benefits
YOUR BLUE VIEW VISION PLAN BENEFITS	IN-NETWORK	OUT-OF-NETWORK	FREQUENCY
Routine Eye Exam A comprehensive eye examination	$10 copay	Up to $40 allowance	Once every 12 months
Eyeglass Frames One pair of eyeglass frames	$130 allowance, then 20% off any remaining balance	Up to $45 allowance	Once every 24 months
Eyeglass Lenses (instead of contact lenses) One pair of standard plastic prescription lenses: Single vision lenses Bifocal lenses Trifocal lenses	$0 copay $0 copay $0 copay	Up to $25 allowance Up to $40 allowance Up to $55 allowance	Once every 24 months
Eyeglass Lens Enhancements When obtaining covered eyewear from a Blue View Vision provider, you may choose to add any of the following lens enhancements at no extra cost. Transitions Lenses (for a child under age 19) Standard polycarbonate (for a child under age 19) Factory scratch coating	$0 copay $0 copay $0 copay	No allowance when obtained out-of-network	Same as covered eyeglass lenses
Contact Lenses (instead of eyeglass lenses) Contact lens allowance will only be applied toward the first purchase of contacts made during a benefit period. Any unused amount remaining cannot be used for subsequent purchases in the same benefit period, nor can any unused amount be carried over to the following benefit period. Elective conventional (non-disposable) Elective disposable Non-elective (medically necessary)	$130 allowance, then 15% off any remaining balance $130 allowance (no additional discount) Covered in full	Up to $105 allowance Up to $105 allowance Up to $210 allowance	Once every 24 months

This is a primary vision care benefit intended to cover only routine eye examinations and corrective eyewear. Blue View Vision is for routine eye care only. If you need medical treatment for your eyes, visit a participating eye care doctor from your medical network. Benefits are payable only for expenses incurred while the group and insured person’s coverage is in force. This information is intended to be a brief outline of coverage. All terms and conditions of coverage, including benefits and exclusions, are contained in the member’s policy, which shall control in the event of a conflict with this overview. This benefit overview is only one piece of your entire enrollment package.

This is not a comprehensive list – please refer to the member Certificate of Coverage for a complete list.

Combined Offers: Not to be combined with any offer, coupon, or in-store advertisement.
Excess Amounts: Amounts in excess of covered vision expense.
Sunglasses: Plano sunglasses and accompanying frames.
Safety Glasses: Safety glasses and accompanying frames.
Not Specifically Listed: Services not specifically listed in this plan as covered services.
Lost or Broken Lenses or Frames: Any lost or broken lenses or frames are not eligible for replacement unless the insured person has reached his or her normal service interval as indicated in the plan design.
Non-Prescription Lenses: Any non-prescription lenses, eyeglasses or contacts. Plano lenses or lenses that have no refractive power.
Orthoptics: Orthoptics or vision training and any associated supplemental testing.

Optional savings from Blue View Vision In-Network Providers only:

Retinal Imaging

At member’s option can be performed at time of eye exam
In-network Member Cost (after any applicable copay): Not more than $39

Eyeglass Lens Upgrades

When obtaining eye wear from a Blue View Vision provider, you may choose to upgrade your new eyeglass lenses at a discounted cost. Eyeglass lens co-payment applies.
In-network Member Cost (after any applicable copay):
- Transitions lenses (Adults) - $75
- Standard Polycarbonate (Adults) - $40
- Tint (Solid and Gradient) - $15
- UV Coating - $15
- Progressive Lenses (Please ask your provider for his/her recommendation as well as the available progressive brands by tier.)
  - Standard - $65
  - Premium Tier 1 - $85
  - Premium Tier 2 - $95
  - Premium Tier 3 - $110
- Anti-Reflective Coating (Please ask your provider for his/her recommendation as well as the available coating brands by tier.)
  - Standard - $45
  - Premium Tier 1 - $57
  - Premium Tier 2 - $68
- Other Add-ons - 20% off retail price

Additional Pairs of Eyeglasses

Anytime from any Blue View Vision network provider.
In-network Member Cost (after any applicable copay):
- Complete Pair - 40% off retail price
- Eyeglass materials purchased separately - 20% off retail price

Eyewear Accessories

In-network Member Cost (after any applicable copay)
Items such as non-prescription sunglasses, lens cleaning supplies, contact lens solutions, eyeglass cases, etc. - 20% off retail price

Contact Lens Fit & Follow-up

A contact lens fitting and up to two follow-up visits are available to you once a comprehensive eye exam has been completed.
In-network Member Cost (after any applicable copay):
- Standard contact lens fitting (Standard fitting includes spherical clear lenses for conventional wear and planned replacement. Examples include but are not limited to disposable and frequent replacement.) - Up to $55
- Premium contact lens fitting (Premium fitting includes all lens designs, materials and specialty fittings other than standard contact lenses. Examples include but are not limited to toric and multifocal.) - 10% off retail price

Conventional Contact Lenses

In-network Member Cost (after any applicable copay)
- Discount applies to materials only - 15% off retail price

Discounts are subject to change without notice. Discounts are not ‘covered benefits’ under your vision plan and will not be listed in your certificate of coverage. Discounts will be offered from in-network providers except where state law prevents discounting of products and services that are not covered benefits under the plan. Discounts on frames will not apply if the manufacturer has imposed a no discount policy on sales at retail and independent provider locations. Some of our in-network providers include:

Glasses.com
Contacts Direct
Lens Crafters
Pearle Vision
Optical
Sears Optical
JCPenney Optical

Additional Savings Available

Additional savings available through our special offers program. Discounts cannot be used in conjunction with your covered benefits.

Savings on items like additional eyewear after your benefits have been used, non-prescription sunglasses, hearing aids and even LASIK laser vision correction surgery are available through a variety of vendors. Just log in at empireblue.com, select discounts, then Vision, Hearing & Dental.

If you choose to, you may instead receive covered benefits outside of the Blue View Vision network. Just pay in full at the time of service, obtain an itemized receipt, and file a claim for reimbursement up to your maximum out-of-network allowance.

If you choose to receive covered services or purchase covered eyewear from an out-of-network provider, network discounts will not apply and you will be responsible for payment of services and/or eyewear materials at the time of service. Please complete an out-of-network claim form and submit it along with your itemized receipt to the fax number, email address, or mailing address below. To download a claim form, log in at empireblue.com, or from the home page menu under Support select Forms, click Change State to choose your state, and then scroll down to Claims and select the Blue View Vision Out-of- Network Claim Form.

You may instead call member services at (866) 723-0515 to request a claim form.

Fax: 866-293-7373
Email: oonclaims@eyewearspecialoffers.com
Mail: Blue View Vision Attn: OON Claims P.O. Box 8504
Mason, OH 45040-7111