What Is Inside…
Your Sprint Vision Care Plan __________________________ 2
A Look At Vision Care Coverage ____________________________ 2
Eligibility & Enrollment ______________________________ 5 How Vision Care Works ______________________________ 5
Finding Providers _______________________________________ 6
What Is Covered ___________________________________ 6
Eye Exams ____________________________________________ 6 Lenses And Frames ______________________________________ 6 Contact Lenses _________________________________________ 7 Laser Eye Surgery ______________________________________ 7 Low Vision Benefits ______________________________________ 9 Coordinating With Medical Coverage _______________________ 11 Coverage Under An HMO ________________________________ 11
What Is Not Covered _______________________________ 11
Special Services And Supplies ____________________________ 12
Filing Vision Care Claims ____________________________ 12
If Your Provider Is Not A Member Of The Network _____________ 12 Disputing Your Coverage or Claim Determination _____________ 13
Helpful Numbers __________________________________ 13 As Your Needs Change ______________________________ 13 When Coverage Ends _______________________________ 14 Other Important Information ________________________ 14 This Coverage Information
Section of the Summary Plan Description (“SPD”) for Sprint Vision Care Plan has been created using simple terms and in an easy-to-understand format This Section will use the terms “we”, “our” or “us” to refer to Sprint or its wholly-owned US
subsidiary and to “you” or “your” to refer to our employees (and their Eligible Dependents as applicable) eligible to participate in the Vision Care Plan as described below.
Sprint intends to continue the Vision Care Plan. However, Sprint reserves the right to change or discontinue any or all benefits under this plan, at any time.
Vision Care Benefits
Your Sprint Vision Care Plan
On the job or at home — good vision helps us perform at our best. Yet, while good vision is important, it is something most of us take for granted. Often, it is because we do not take the time to properly have our eyes examined. So, to encourage you and your family to see the benefits of healthy eye care, Sprint provides a Vision Care Plan offering.
Surency Vision, a wholly-owned subsidiary of Delta Dental of Kansas, and EyeMed Vision Care has aligned to provide you with a vision program, offering the freedom to choose providers from both independent private practitioners and retail chains. The retail chains included in the EyeMed Sprint Access network are: LensCrafters, Pearle Vision, Target Optical, JCPenney Optical and Sears Optical.
You and your family can save on vision exams, eyeglasses, contact lenses and laser eye surgery when you receive services from Surency Vision using providers in the EyeMed Sprint Access network. You may use any provider, but higher benefits are paid if you use eye care professionals in the EyeMed Sprint Access network.
A Look At Vision Care Coverage
Here is a look at the vision care coverage. Please be sure to read through this entire summary booklet for coverage details and important information.
Service Network Provider Out-Of-Network Provider (You get reimbursed)
Eye Exams (Once per calendar year)
Plan pays 100%after $15
co-payment* Up to $45 Lenses (Once per calendar year) Single Vision Lined Bifocals
(Includes lenticular lenses, scratch resistant coating, ultraviolet coating, tints
and dyes, and
polycarbonate lenses for children under the age of 19)**
Plan pays 100% after $25 co-payment
Plan pays 100% after $50 co-payment
Vision Care Benefits
Lined TrifocalsStandard Progressive***
Plan pays 100% after $50 co-payment
Plan pays 100% after $50 co-payment
Up to $85
Up to $5 for tints and dyes
Frames (One pair per calendar year)
Plan pays 100% of
allowable amount of $140; you will receive a 20% discount on the charges over the allowable amount; the plan also allows a 20% discount on non-prescription sunglasses and a 40% discount on an additional pair of glasses or prescription sunglasses Up to $47 Contacts (Once per calendar year) Lenses Standard Contact Lens Fit and Follow Up
Premium Contact Lens Fit and Follow Up
Plan pays 100% for up to $140 once per calendar year for contact lenses Plan pays 100% after $25 co-payment for medically necessary contacts
The maximum you pay is $55 for standard lens fitting and follow up
You receive 10% off retail for premium lens fitting and follow up
Up to $105 once per calendar year for contact lenses
Up to $185 once per calendar year for medically necessary contacts
Vision Care Benefits
Laser Eye Surgery
LasikPlus Center 1-877-637-9090
The “featured provider” provides greater discounts and extra value;
The maximum you pay is:
U.S. Laser Network 1-877-637-9090 Discounted rates available; The maximum you pay is: No discounts available Traditional LASIK w/ Bladefree (enhancements up to one year) $695 per eye* PRK $1,500 per eye** Traditional LASIK w/ Bladefree (enhancements for life) $1,395 per eye LASIK $1,800 per eye** Custom or Wavelight LASIK w/ Bladefree (enhancements for life) $1,895 per eye Custo m LASIK $2,300 per eye**
*For vision that has a better than -2 prescription for nearsightedness (or better than -1 with astigmatism), and other restrictions may apply
** Prices do apply towards Custom PRK or Bladefree procedures
Customer Service Surency Vision: 1- 866-818-8805
Providers/Facilities
Surency Vision together with EyeMed Vision Care, offer a network that includes more than 73, 000 retail and independent private practitioners at nearly 27, 000 locations. To locate a provider near you, visit
www.surency.com
. Select the Sprint Access Network.
*Co-payment is a predetermined amount that you pay directly to the doctor or other health care provider when you receive services. ** Member Preferred pricing on non-covered lens options (i.e. photochromic lenses, anti-reflective coating, premium progressive lenses, high index lenses, etc.) when using a network provider. ***Standard progressive lenses require a certain sized frame to allow enough vertical height to give a smooth transition from distance vision down to reading. Premium progressive lenses provide a wider reading area than standard progressive lenses. The lenses also have a high level of customization, allowing users to wear them with any frame. There is only one material co-payment when lenses and frames are purchased at the same visit.
Vision Care Benefits
could add up to hundreds of dollars in savings. See the “Laser Eye Surgery” section for more information.
Surency Vision members have freedom of choice in selecting frames. Your benefits provide guaranteed savings whether you choose a frame that is covered or one that exceeds the plan allowance. If you choose a frame valued at more than the plan’s allowance, the difference you will pay is based on Surency Vision’s low, discounted member pricing when you use a network or retail provider.
Surency Vision offers valuable savings including a 40% discount on non-covered pairs of prescription glasses (lenses and a frame). Services must be received within 12 months from the same provider who provided your last covered eye exam.
You cannot be billed for more than $55 for your Standard contact lens Fit and Follow-up exams so that you may use your entire $140 contact lens benefits for materials.
Eligibility & Enrollment
For rules on who is eligible to be covered, enrollment, and effective dates of coverage, see the separate Eligibility & Enrollment Section SPD incorporated herein by reference on the Benefits Overview page of iConnect under the Summary Plan Descriptions (SPD) column.
How Vision Care Works
The Surency Vision network of eye care providers, featuring EyeMed’s independent private practitioners and retail chains, works like other health care networks — when you use network providers for your vision care services, you receive higher benefits. If you choose out-of-network providers, limited benefits are paid.
When you receive services, simply inform the provider that you have coverage with Surency Vision featuring the EyeMed Sprint Access plan and provide the personal information that is required (including your identification number and employer’s name — Sprint ). The EyeMed provider will confirm your membership and you will receive benefits. If you are not eligible for benefits at that time, the provider will communicate that to you.
Vision Care Benefits
Finding Providers
Finding a network provider, either an independent private practitioner or a retail chain, is the first step towards maximizing your Surency Vision benefits.
Two options to find a provider:
Call Surency Vision’s toll-free Member Services Support Line at:
1-866-818-8805
Visit the Surency Vision website at www.surency.com
What Is Covered
A nationwide network of vision care providers, both independent private practitioners and retail chains — provides your Sprint vision care coverage. Surency Vision covers most vision care expenses and pays higher benefits if you use network providers. Here is how Surency Vision covers vision care services and supplies.
Eye Exams
Surency Vision covers routine eye exams once per calendar year. When performed by an EyeMed Sprint Access network provider, Surency Vision fully covers the cost of the eye exam after you pay a $15 co-payment.
If you use an out-of-network provider, Surency Vision reimburses up to $45 towards your eye exam.
Lenses And Frames
Surency Vision provides benefits for lenses and frames once per calendar year, after you pay a $25 co-payment toward the cost of single vision lenses or a $50 co-payment toward the cost of bifocal, trifocal and standard progressive lenses. When you use an EyeMed Sprint Access network provider, lenses (single vision, lined bifocal, lined trifocal, lenticular, and lens coating such as scratch resistant, ultraviolet, and polycarbonate lenses for children under the age of 19) are covered in full. A $40 co-payment towards polycarbonate lenses for individuals over the age of 19 applies. Frames are covered 100% up to the retail frame allowance of $140.
If you use an out-of-network provider, materials are covered up to the following limits:
Materials
(Lenses And Frames)
Plan Pays With
Out-of-Network Providers…
Vision Care Benefits
Frames (one pair per calendar year)
up to $47
Optional features that are not medically necessary but are sometimes chosen for cosmetic reasons (such as progressive lenses,
anti-reflective coating, blended lenses, oversized lenses 61 mm or larger or special lens tints) are discounted for Surency Vision members when using an EyeMed Sprint Access network provider. See “Special Services And Supplies” for details.
Contact Lenses
Benefits are provided for both elective and medically necessary contact lenses.
When using an EyeMed Sprint Access network provider, if you elect to order contact lenses instead of eyeglasses, you will have an allowance of up to $140 once per calendar year for the contact lenses. A
Standard contact lens Fit and Follow-up exam will be covered after $55 co-pay. You will receive 10% off retail prices if receiving a Premium contact lens Fit and Follow-up exam. When using an out-of-network provider, the allowance when purchasing contact lenses (instead of eyeglasses) is up to $105 once per calendar year after you pay a $15 co-payment for a comprehensive routine eye exam.
A contact lens eye exam or fit and follow-up exam is a special exam to ensure the proper fit of your contacts and evaluating your vision with the contacts.
Medically necessary contact lenses may be covered in full (with an in network provider) after a $25 co-payment when submitted and pre-approved by Surency Vision (up to $185 with an out-of-network provider) when needed due to:
Cataract surgery;
Extreme visual acuity problems that cannot be corrected with
glasses;
Anisometropia — different refractive power in each eye; and Keratoconus — protrusion of the cornea.
Dollar allowances are for two lenses — if you need only one lens, the allowance is one-half the amount listed. In addition, if you order contact lenses one year, you can order eyeglass lenses and frames at any time during the next calendar year.
Laser Eye Surgery
Vision Care Benefits
members will receive 5 percent off of the promotional price. Through this program, the most you will pay for laser surgery is:
For… The Most You Will
Pay Is Up To…
PRK $1,500 per eye
LASIK $1,800 per eye
Custom LASIK (Using wavelight technology only — other technologies not covered under Custom LASIK)
$2,300 per eye
Surency Vision, together with EyeMed and U.S. Laser Network have arranged for members to receive even further discounts when having LASIK surgery through one of the LasikPlus Centers across the U.S. When using a LasikPlus Center, the maximum you will pay is:
For… The Most You Will
Pay Is Up To… Traditional Lasik w/ Bladefree (enhancements up to 1 year) $695 Traditional Lasik w/ Bladefree (enhancements for life) $1,395 per eye
Custom or Wavelight LASIK w/ Bladefree (enhancements for life)
$1,895 per eye
Follow these steps to learn the facts and find out if it’s right for you. 1. Contact U.S. Laser Network at: 1-877-5LASER6 to:
Get details about the program and laser vision correction; Learn what to expect during surgery;
Ask questions about the procedure; and Find a network provider in your area.
2. Confirm your eligibility before scheduling an appointment. Log on to www.Surency.com or call Surency Member Services at 1-866-818-8805.
3. Call your network provider to verify their participation in the program.
4. Schedule a complimentary screening with your network provider to learn more about laser vision correction.
Eye Surgery…
Vision Care Benefits
If you decide to have laser vision correction, your network provider will make arrangements with one of the approved laser surgeons and centers. The network provider will also provide your pre-operative care*. Post-procedure care is coordinated between your Surency Vision network provider and your U.S. Laser network laser surgeon. * While the laser vision correction screening and consultation with your network provider is complimentary, if you have a pre-operative exam and do not proceed with the surgery, your network provider may charge an exam fee of up to $100.
Low Vision Benefit
The Low Vision benefit is available to Covered Persons who have severe visual problems that are not correctable with regular lenses and is subject to prior approval by Surency Consultants.
Member Doctor
Benefit Non Member Benefit
Supplementary
Testing Covered in Full Up to $125.00
Complete low vision analysis/diagnosis which includes a comprehensive examination of visual functions, including the prescription of corrective eyewear or vision aids where indicated.
Member Doctor
Benefit Non Member Benefit
Supplemental Care
Aids 75% of Cost 75% of Cost
Subsequent low vision aids as Visually Necessary or Appropriate.
Copayment for Supplemental Aids: 25% payable by Covered Person.
Benefit Maximum
The maximum benefit available is $1000.00 (excluding Copayment) every two years.
Non-Member Provider Benefit
Vision Care Benefits
Exclusions and limitations of Benefits Patient Options
This Plan is designed to cover visual needs rather than cosmetic materials. When the Covered Person selects any of the following extras, the Plan will pay the basic cost of the allowed lenses, and the Covered Person will pay the additional costs for the options:
Optional cosmetic processes.
Premium progressive lenses.
Anti-reflective coating. Color coating. Mirror coating. Blended lenses. Cosmetic lenses. Laminated lenses. Oversize lenses.
Progressive multifocal lenses.
Certain limitations on low vision care.
A frame that costs more than the Plan allowance.
Contact lenses (except as noted elsewhere herein).
Not Covered
Under the low vision benefit, there is no benefit for professional services or materials connected with:
Orthoptics or vision training and any associated supplemental testing; plano lenses (less than a ±.50 diopter power); or two pair of glasses in lieu of bifocals;
Replacement of lenses and frames furnished under this Plan which are lost or broken, except at the normal intervals when services are otherwise available;
Medical or surgical treatment of the eyes;
Corrective vision treatment of an Experimental Nature;
Costs for services and/or materials above Plan Benefit allowances;
Vision Care Benefits
Coordinating With Medical Coverage
If you have an accidental injury or illness that affects your eyesight, coverage may be provided by your medical provider. Submit the claim to Surency Vision for consideration, after your medical provider has processed the claim.
Coverage Under An HMO
If you are enrolled in a Health Maintenance Organization (HMO), your coverage may include basic vision care benefits separate from the coverage provided under the Vision Care option of the Sprint Plan. Vision expenses not covered by the HMO may be submitted if you are a plan participant.
What Is Not Covered
Vision care coverage does not cover the following expenses:
Services covered by your medical provider or another benefit plan; Services or supplies payable under Workers’ Compensation or
self-employment laws;
Services performed or supplies ordered before your coverage is
effective;
Services or supplies provided by an individual who is not an
optometrist, ophthalmologist, or dispensing optician;
Completing insurance forms;
Orthoptics, vision training or supplemental testing; Nonprescription sunglasses and subnormal vision aids;
Replacing lost, stolen or broken lenses or frames, except when
within the normal interval allowed under this coverage;
Duplicate glasses, lenses or frames; Cosmetic materials;
Services or supplies connected with plano lenses, or two pairs of
glasses instead of bifocals;
More than one eye refraction within a calendar year;
More than one pair of eyeglass lenses or contact lenses within a
calendar year;
More than one set of frames within a calendar year; Medical or surgical treatment, drugs or medicines; Free services or supplies;
Experimental services or supplies;
Is Vision Covered Elsewhere?
Other vision coverage may be available to you — be sure to check over your health care provider information for vision care benefits.
Vision Care Benefits
Custom LASIK procedures unless using the wavefront technology;
all other technologies not covered under Custom LASIK;
Service agreements (insurance for loss or replacements);
Services or supplies for a disease, defect or injury resulting from
an act of war; and
Services or supplies for which benefits are payable through a
government health care program.
Special Services And Supplies
Sprint’s Vision Care Plan is designed to cover visual needs rather than cosmetic materials. If you select any of the following extras, you will be responsible for the cost of these options:
Blended lenses;
Premium Progressive lenses; Anti-reflective coating;
Oversized lenses;
Tinted lenses — except pink #1 or pink #2; Progressive multifocal lenses;
Laminating of lens or lenses; and
A frame that costs more than the coverage allowance.
Note: member providers provide discounts for these special services
and supplies.
Filing Vision Care Claims
As long as you use an EyeMed Sprint Access network provider, there are no claims to file — the provider does it for you.
If Your Provider Is Not A Member Of The Network
If you use an out-of-network provider, you must pay for the services and submit an itemized receipt to Surency Vision with the following information:
Itemized statements of services received; Covered member’s Identification number;
Covered member’s name, phone number and address; Member’s employer; and
Patient’s name, relationship to member and date of birth.
Out-of-network claims must be submitted within six months from the date the expenses are incurred in order to be considered for
reimbursement.
Confused About What Is Covered?
Vision Care Benefits
The following steps are the most efficient way for members to access their out-of-network Benefit:
1. Visit www.surency.com for an Out-of-Network Claim Form. 2. Schedule an appointment with your provider.
3. Pay for vision care services and materials at the point of care and obtain an itemized receipt from the provider office. 4. Submit the completed claim on the EyeMed Out of Network
claim form, attaching the itemized receipt from the provider. 5. Mail claims for services received from out-of-network providers
to:
EyeMed Vision Care
Attn: Out of Network (OON) Claims P.O. Box 8504
Mason, Ohio 45040-7111
6. A reimbursement check will be sent to you for benefits based on the out-of-network EyeMed Benefit levels.
Disputing Your Coverage or Claim Determination
If you or your dependent(s) are denied participation in, or eligibility to participate in, a welfare plan, or if you disagree with a claim determination, you have the right to file an appeal to request reconsideration. See the Legal
Information document for important information on how to appeal and the
applicable timeframes associated with the appeals process.
Helpful Numbers
Customer Service Number:
Surency Vision:
LasikPlus Center: U.S. Laser Network:
1- 866-818-8805 1-877-5LASER6 1-877-5LASER6
To find providers online…
Surency Vision website: www.Surency.com
As Your Needs Change
In certain situations, you may change your enrollment in your Sprint Vision Care Plan – see the Life Events Section that is also part of a Summary Plan Description for the Plans, incorporated herein by reference on the Benefits site of i-Connect under Summary Plan Descriptions.
Vision Care Benefits
When Coverage Ends
For information on when your coverage under the Vision Care Plan ends, see the separate Eligibility & Enrollment Section of the SPD incorporated herein by reference on the Benefits site of i-Connect under Summary Plan Descriptions.
Other Important Information
For other important information about the Vision Care Plan’s Plan Sponsor and Administrator, participating employers, Plan