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31SN0164 08/12
EMPLOYEE BENEFITS
A product of Blue Cross and Blue Shield of Louisiana
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BENEFITS you caN SEEStandard Vision Benefits
Eye exams Your employees pay little or no copayment for a
comprehensive eye exam.
Eyeglass lenses Your employees pay little or no copayment for
single vision, bifocal or trifocal lenses.
Eyeglass frames Your employees pay little or no copayment for
frames from the Davis Vision Collection, or receive a $150
allowance toward the cost of other frames.
contact lenses Your employees pay little or no copayment for
contact lenses from the Davis Vision Collection, or receive a $130
allowance toward the cost of contact lenses.
Lasik surgery Your employees may access discounts from
participating providers; but, this is not an insured benefit.
Davis Vision is an independent company that provides an
extensive network of vision care providers on behalf of Blue Cross
and Blue Shield of Louisiana.
IN-NETWORK BENEFITS VISION PLAN OPTIONS
PLaN 1 PLaN 2 PLaN 3
Frequency - Once Every:
Eye Health Examination Including Dilation (when professionally
indicated) 12 Months 12 Months 12 Months
Spectacle Lenses 12 Months 12 Months 12 Months
Frame 12 Months 24 Months 24 Months
Contact Lens Evaluation, Fitting and Follow Up 12 Months 12
Months 12 Months
Contact Lenses (in lieu of eyeglasses) 12 Months 12 Months 12
Months
Copayments
Eye Health Examination $0 $0 $10
Eyewear (Spectacle Lenses and/or Frames) $0 $15 $25
(When visiting a Davis Vision network provider)
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There’s no such thing as a plan that’s too good. That’s why each
of our vision plans is packed with
features that don’t cost you or your employees anything
extra.
one-year breakage warranty Eyeglasses covered by your plan come
with a one-year for eyeglasses warranty for repair or replacement,
which begins on the date you receive your glasses. Your plan
covers:
• Spectaclelenses
• DavisVisioncollectionframes
• Nationalretailerframes,whereexclusivecollectionis not
displayed
Medically necessary contacts Your provider may presrcibe contact
lenses in lieu of eyeglasses for treatment of certain conditions.
When contact lenses are medically necessary, they will be covered
subject to prior approval and applicable copayments and
allowances.
Replacement contact lens It’s easy to replace your contacts
through the Lens 1-2-3 program
mailorderprogram.Justcall1-800-LENS-123orvisit www.lens123.com with
your prescription to get started.
20% discount At most of our network retailers, you’ll get a 20%1
discount on items not covered by your plan, like second pairs,
sunglasses, etc. In most cases, disposable contact lenses are
available at a 10%1 discount.
Laser vision correction You can get up to 25% off of the cost of
laser vision discounts correction surgery when you use doctors in
the Eye Centers of Excellence network.
For consistency and accuracy, when adding vision benefits to
existing medical insurance with a first-of-the-month billing date,
the new benefits will have a first-of-the-month effective date. The
same applies for groups with a 15th-of-the-month billing date.
Eligibility for actively at work, full-time employees requires a
minimum of 30 hours per week for our medical, vision and other
ancillary products.
Groups may only choose one vision plan and one premium funding
contribution type.
General conditions
Groups with 2-9 eligible employees may only choose employer-paid
premium funding contribution.
Employer-paid:
contributory:
Voluntary:
100% Employer funding 100% of eligible employees must enroll
25%-99% Employer funding Greater of 75% or 10 eligible employees
must enroll
0%-24% Employer funding Greater of 25% or five eligible
employees must enroll for groups with 10-35 eligible employees
Greater of 25% or 10 eligible employees must enroll for groups
with more than 36 eligible employees
Features
contribution Requirements Participation RequirementsPremium
Funding
1 Discount not available at Walmart and Sam’s Club
locations.
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This document is intended as a proposal, and is not a contract.
You should check your contract for the full details, benefits and
exclusions of your plan. In any case where there is a discrepancy
between your con-tract and this document, the terms of your
contract will prevail.
1-800-247-9368We’re available Monday through Friday, 8 a.m. – 5
p.m.
www.bcbsla.comFind help online 24 hours a day.
5525 Reitz ave.Baton Rouge, La 70809-3802
We have eight regional offices around the state. Find us at any
of the following locations. We’d love to see you.
Phone
online
Mail
Local
customer Service
We’re easy to find and happy to help you. If you need to reach
us:
Alexandria
318-448-16604508 Coliseum Blvd., Suite A
Alexandria, LA 71303
Baton Rouge
225-295-25565525 Reitz Ave.
Baton Rouge, LA 70809-3802
Houma
985-223-34991437 St. Charles Street, Suite 135
Houma, LA 70360
Lafayette
337-232-75275501 Johnston St., Suite 200
Lafayette, LA 70503
Lake Charles
337-562-0595219 West Prien Lake Road
Lake Charles, LA 70601-8450
Monroe
318-323-14793130 Mercedes Dr. Monroe, LA 71201
New Orleans
504-832-58003501NorthCausewayBlvd.,Suite600
Metairie, LA 70002
Shreveport
318-795-0573411 Ashley Ridge Blvd. Shreveport, LA 71106
Regional offices
Blue Cross and Blue Shield of Louisiana is an independent
licensee of the Blue Cross and Blue Shield Association and
incorporated as Louisiana Health Service & Indemnity
Company.
