Plus & Materials Only Plans
G R O U P S 2 +
Vision Care
Quality
for Groups Big and Small
Offer your group clients a fully insured vision plan that provides one of the greatest values
in the vision care industry. Employees receive complete vision care coverage for a
premium that is very affordable.
Groups have the option of selecting a complete vision solution that provides coverage for
exams and optical materials; or opt for a plan design which only covers frames and
lenses, or contact lenses for each plan period.
The Avesis Vision Plan offer a generous vision care
benefit for your employee groups and their dependents.
Members receive the greatest value if they receive
services from in-network providers.
Avesis Vision Groups
Covered employees have the option of utilizing a
national network of over 30,000 providers. Members
may choose between independent optometrists and
ophthalmologists as well as national and regional retail
vision centers.
An Expansive Provider Network
You can offer the Avesis Vision Plan with a low
participation requirement of only 2 enrolled employees.
There are no pre-existing exclusions, and rates are
guaranteed up to 24 months.
Simple Underwriting
Groups can take advantage of forefront advancements in online plan administration and
individual benefit research. Plan administrators have tools which simplify the billing and
enrollment process. Additionally, members have access to important plan information
such as provider data, eligibility dates, and more.
Technology
The Plus and Materials only plans provide coverage for optical materials such as frames and spectacle
lenses. Members who elect to receive contact lenses in lieu of frames and spectacle lenses will receive a
$130 allowance after the Avesis preferred pricing is applied. Groups who select the Plus Plan will also
receive vision examination coverage.
The materials only plan provides coverage for optical materials. It is an excellent addition to a health care
package that contains a yearly benefit for a vision examination.
Vision Exam
Frame (within plan allowance) Spectacle Lenses
Standard Single Vision Standard Bifocal Standard Trifocal Standard Lenticular Progressive Lenses
Specialty Lenses
Contact Lenses
Elective (up to plan Allowance) Medically Necessary
Lens Options (coatings, tints, etc.) Laser Vision Correction Additional Purchases
Covered in Full (co-pay may apply)
Covered in Full*
Covered in Full* Covered in Full* Covered in Full* Covered in Full*
20% retail discount, plus a
$50 allowance
20% retail discount plus the
corresponding standard lens payment
Up to $130 allowance Covered in Full
20% retail discount Up to 25% retail discount Unlimited 20% retail discount
Up to $35
Up to $45
Up to $25 Up to $40 Up to $50 Up to $80 Up to $40
Corresponding standard lens reimbursement
Up to $130 allowance Up to $250
N/A N/A N/A
In-Network
Services / Materials
Co-pays Frequency
Avesis Vision Groups of 2 or more
Out-of-Network
* Covered in full after the material co-pay is met (if applicable). Not available in Washington or New York.
Excluded with the Materials Only Plan
Vision Examination* Every 12 Months
Spectacle Lenses Every 12 Months
Frames Every 24 Months
Contact Lenses** Every 12 Months
* Vision examination is not included with the Materials Only Plan
** In lieu of frames and lenses
Vision Examination Co-pay $10.00
Materials Co-pay $10.00
(Materials Only Plan)or $25.00
(Plus Plan)Contact lenses are not subject to materials co-pay.
Plus and Materials Only Plan
Underwritten by: Fidelity Security Life Insurance Company, Kansas City, MO Policy #: VC-16, Form M-9059
Voluntary 75% Participation Voluntary 75% Participation Voluntary 75% Participation 12/12/24/12 12/12/24/12 12/12/24/12 12/12/24/12 12/24/12 12/24/12
Employee Only $8.81 $7.32 $8.47 $6.40 $6.16 $5.13
Employee + Family $20.26 $16.84 $19.47 $14.72 $14.17 $14.17
Employee Only $8.81 $7.32 $8.47 $6.40 $6.16 $5.13
Employee + One $15.42 $12.81 $14.82 $11.20 $10.78 $8.98
Employee + Family $22.91 $19.03 $22.01 $16.64 $16.02 $13.34
Employee Only $8.81 $7.32 $8.47 $6.40 $6.16 $5.13
Employee + Spouse $16.54 $13.83 $16.00 $11.20 $11.64 $9.70
Employee + Child(ren) $18.15 $15.08 $17.44 $13.44 $12.69 $10.57
Employee + Family $23.35 $19.40 $22.44 $16.64 $16.32 $13.59
Plus Plan A
$10/$10 Co-pay
Plus Plan B
$10/$25 Co-pay
Materials Only
$10 Co-pay
Policy and rates are guaranteed for up to 24 months from the group’s effective date. Not available in Washington or New York.
Plus and Materials Only Plan Rates
Limitations: This plan is designed to cover eye examinations and corrective eyewear. It is also
designed to cover visual needs rather than cosmetic options. Should the member select options that
are not covered under the plan, as shown in the schedule of benefits, the member will pay a
discounted fee to the participating Avesis provider. Benefits are payable only for services received
while the group and individual member’s coverage is in force.
Exclusions: There are no benefits under the plan for professional services or materials connected
with and arising from: 1) Orthoptics of vision training; 2) Subnormal vision aids and any supplemental
testing; 3) Plano (non-prescription) lenses, sunglasses; 4) Two pair of glasses in lieu of bifocal lenses;
5) Any medical or surgical treatment of eye or support structures; 6) Replacement of lost or broken
lenses, contact lenses or frames, except when the member is normally eligible for services; 7) Any eye
examination or corrective eyewear required by an employer as a condition of employment; 8) Services
or materials provided as a result of Workers Compensation Law, or similar legislation, required by any
governmental agency whether Federal, State or subdivision thereof.
Limitations: This plan is designed to cover corrective eyewear. It is also designed to cover visual
needs rather than cosmetic options. Should the member select options that are not covered under the
plan, as shown in the schedule of benefits, the member will pay a discounted fee to the participating
Avesis provider. Benefits are payable only for expenses incurred while the group and individual
member’s coverage is in force.
Exclusions: There are no benefits under the plan for professional services or materials connected
with and arising from: 1) Orthoptics of vision training; 2) Subnormal vision aids and any supplemental
testing; 3) Plano (non-prescription) lenses, sunglasses; 4) Two pair of glasses in lieu of bifocal lenses;
5) Any medical or surgical treatment of eye disease or injury; 6) Replacement of lost or broken lenses,
contact lenses or frames, except when the member is normally eligible for services; 7) Any corrective
eyewear required by an employer as a condition of employment; 8) Services or materials provided as
a result of Workers Compensation Law, or similar legislation, required by any governmental agency
whether Federal, State or subdivision thereof; 9) Any vision examination.
PLUS PLAN LIMITATIONS AND EXCLUSIONS
MATERIALS ONLY PLAN LIMITATIONS AND EXCLUSIONS
325 Cedar Street, Suite 800 Saint Paul, MN 55101 • ph 651-649-3503 800-620-5010 fax 651-649-3502 • www.directbenefits.com
I. EMPLOYER INFORMATION
Employer Name: ____________________________________ Tax ID#: ______________________________________________ DBA Name (if other than above) _______________________________________________________________________________ Business Address: ____________________________ City: ____________________ State: ________ Zip: ______________ Mailing Address: ______________________________ City: ____________________ State: ________ Zip: ______________ Key Contact: ______________________________________________ Title: ________________________________________ Phone Number: ____________________ Fax Number: ____________________ E-mail: ____________________________ Executive Contact: __________________________________________
Phone Number: ____________________ Fax Number: ____________________ E-mail: ____________________________ Type of Business:
Proprietorship
Corporation
Partnership
Other (Specify) ________________
If any subsidiary or affiliated companies are to be insured or any Employees are working at a location other than the address above, please explain:
__________________________________________________________________________________________________________ __________________________________________________________________________________________________________ Will this plan replace any existing coverage:
Yes
No (if yes, indicate name and address of existing insurer) Name: __________________________________
Business Address: __________________________ City: ______________________ State: ________ Zip: ______________ (If “yes,” are any employees on COBRA)?
Yes
No How many? ________________________________ Effective date of existing coverage: ________________________________________
Termination date of existing coverage (if applicable): ____________________________
Number of full-time employees: ______________________________________ Number applying: ______________________ Are domestic partners covered under this plan?*
Yes
No *except as required by state law
Unless your specific state mandates otherwise, do you wish to cover dependents until age 26, regardless of financial dependency, residency, student status or marital status?
Yes
No
II. PLAN SELECTION
Employer Paid VoluntaryExam Lenses Frame Contact Lenses
AVESIS Advantage Vision Basic Plan12 months, 12 months, 12 months, 12 months AVESIS Advantage Vision Enhanced Plan
12 months, 12 months, 24 months, 12 months AVESIS Advantage Vision Plus Plan
12 months, 12 months, 24 months, 24 months AVESIS Advantage Vision Preferred Plus Plan
12 months, 24 months, 24 months, 24 months Other 24 months, 24 months, 24 months, 24 months __ months, __ months, __ months, __ months Select Tier Structure: 2 Tier 3 Tier 4 Tier
Co-payment: ( ) Split $ ________ Examination $ ________ Other
$ ________ Frames/Lenses $ ________ Other
No. of employees Rate Total Remittance
Employee Only ______________ X $ ______ = $ ______________________ Employee + Spouse ______________ X $ ______ = $ ______________________ Employee + Child(ren) ______________ X $ ______ = $ ______________________ Employee + Family ______________ X $ ______ = $ ______________________ TOTAL = $ ______________________
(if other than above)
Application for Vision Care Benefits
Underwritten by Fidelity Security Life Insurance Company
Kansas City, Missouri
A-01157 M-9059, M-9069
Policy No. VC-16, VC-23
III. PREMIUMS
Employee contribution towards premium?:
Yes
No
Employer’s Premium Contribution for: Employees: % ________ Dependents: % ________ Are Employee and Dependent premiums being paid through a Section 125 Plan?
Yes
No Are Employee and Dependent premiums being collected by payroll deduction?
Yes
No Premium received with application: ________________________________________
Note: Please attach a list of all participants to this application. Premiums shall be payable in advance.
IV. ELIGIBILITY(Choose one)
PROBATIONARY PERIOD FOR NEW EMPLOYEES
30 Days 60 Days 90 Days 120 Days 180 Days Other __________________ Probationary Period is Waived for Present Employees: Yes NoELIGIBLE CLASS (Choose One)
The Employees eligible for insurance under the Policy shall be all the full-time Employees of the above-named Employer and each Employee's Dependents. If both husband and wife are Employees, either the husband or wife, but not both, may elect coverage for their Dependents. Eligible Dependents may be added to the Policy on any premium due date.
No Part-time Employee, or his or her Dependents, may be included as Eligible Persons.
As used here, full-time Employee means an Employee who is performing all the usual duties of his or her position at the Employer's usual place of business at least 20-40 or more hours per week. A part-time Employee is an Employee who does not meet this definition.
Dependents may not be included as Eligible Persons unless the Dependent's parent or spouse is covered under the Policy.
The Employees eligible for insurance under the Policy shall be all the Employees of the above named Employer, and each Employee's Dependents. If both husband and wife are Employees, either the husband or wife, but not both, may elect coverage for their Dependents. Eligible Dependents may be added to the Policy on any premium due date.
The Employees eligible for insurance under the Policy shall be __________________________________________________ ______________________________________________________________________________________________________ DATE ELIGIBLE
1. Each Employee included in an Eligible Class on the Policyholder's Effective Date will be eligible on that date, provided the Employee has completed any required probationary period shown below.
2. Each Employee included in an Eligible Class on the Policyholder's Effective Date, and who had partially satisfied the required probationary period prior to the Policyholder's Effective Date, will be eligible for coverage on the first day after completion of the probationary period.
3. Each Employee who enters an Eligible Class AFTER the Policyholder's Effective Date will be eligible on the first day of the calendar month coinciding with or next following:
a. completion of any required probationary period; or
b. the Employee's date of employment, if a probationary period is not required. EMPLOYEE ENROLLMENT
1. Each Employee may request coverage for him or herself and eligible Dependents.
2. The Company reserves the right, based upon Our underwriting procedures, to require that the eligible Employee and/or eligible Dependent of a Policyholder submit an enrollment form and agree to pay any premium contribution, if required, before coverage will become effective for the Employee and/or Dependent.
DELAYED ENROLLMENT
Each Employee who waives or declines insurance when he or she becomes eligible will not be eligible again until the next Policy anniversary date or ____________. If insurance is waived or declined for eligible Dependents then those Dependents will not become eligible again until the next Policy anniversary date or ____________.
PARTICIPATION REQUIREMENT
The Policyholder is required to maintain the minimum participation requirements of the Company as follows:
If part of the premium is derived from funds contributed by the insured Employees, at least 10-25% of the eligible Employees must elect to make the required contribution, and at least 2-100 Employees must be covered on the Policy's Effective Date.
When a contribution is not required by the Employee, then 100% of the eligible Employees must be covered at all times.
V. EFFECTIVE DATE
It is desired that the policy shall become effective at 12:01 A.M. Standard Time at the Employer's address herein, on the _______ day of __________, __ ____ , provided this application shall have been accepted by the Company.
The Policy, if issued, rates are guaranteed for a term of __________ {months} {year(s)}.
The total premium rate is subject to modification based upon any change in benefits, policyholder contributions, number of eligible employees, information provided by the applicant on the application, governmental action or change in law or regulation, any of which, individually or in combination, may affect the Company's risk in underwriting this coverage. The rate guarantee is also subject to change for any regulatory assessments, fees, or taxes created by federal or state governments, and the associated administrative costs.
The Employer hereby makes application to Fidelity Security Life Insurance Company for Vision Care Benefits. The Employer agrees to maintain and furnish any records necessary to administer the plan, and to forward premiums monthly in advance.
The Employer certifies that all the information shown on this application and any attachments are correct and complete and understands that the Insurance Company intends to rely on this information in determining whether or not the enrolling Employees may become insured. It is further understood and agreed that NO INSURANCE WILL BECOME EFFECTIVE UNTIL APPROVED BY THE INSURANCE COMPANY; and that no field representative of the Insurance Company has the authority to modify any conditions of application, or policies, by making any promise or representation. It is understood that the insurance as to any Employee will not become effective on the date insurance should otherwise become effective if he is not at work on such date performing all duties of his occupation and otherwise meets the requirements of the Insurance Company.
I hereby represent that I have reviewed the fraud warning notice (if applicable) on the reverse side of this application for the Group's state of domicile.
Dated at: ________________________________ this ______________________ day of ________ , 20 ______________ Signed for the Employer: ______________________________________ Title: ______________________________________
Separate Billing Required:
Yes
No (if yes, please attach names of classifications, location addresses and contact) We wish to be included in the Avesis e-billing system:
Yes
No
WRITING BROKER'S CERTIFYING STATEMENT
I certify that I have accurately recorded on this application the information supplied by the proposed policyholder(s). Firm Name: ________________________________________________
Broker Name: (print) ______________________________________ Broker No.: ____________________________________ Address: __________________________________ City: ______________________ State: ________ Zip: ______________ Commission Check Payable to: ____________________ Firm Name: ____________________ Tax ID#: __________________ Commission Check Payable to: ____________________ Broker Name: __________________ SS#: ____________________ Broker Signature: __________________________________________ Phone: ______________________________________ This application signed this __________________ day of ____________________ , 20 __________
APPLICATION INSTRUCTIONS
Complete this application form. Be sure to sign where indicated above.
Return the completed application form along with the first month's premium payable to FIDELITY SECURITY LIFE INSURANCE COMPANY to:
Avesis Third Party Administrators, Inc. P.O. Box 316
Owings Mills, Maryland 21117
Subsequent payments to be payable to FIDELITY SECURITY LIFE INSURANCE COMPANY and sent to: Avesis Third Party Administrators, Inc.
P.O. Box 52718 Phoenix, Arizona 85072
FRAUD WARNING NOTICE
For residents of all states (except the following:)
Any person who, with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
Alabama Any person who knowingly presents a false or fraudulent claim for payment of loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution, fines or confinement in prison, or any combination thereof. Arkansas, Louisiana
Rhode Island, West Virginia
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
Colorado It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of
Insurance within the Department of Regulatory Agencies.
District of Columbia WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.
Florida Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
Kansas, Oregon, Texas, Vermont Any person who with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud.
Kentucky Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.
Maine It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.
Maryland Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
Nebraska Any person who, with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application or files a claim containing a materially false or deceptive statement is guilty of insurance fraud.
New Jersey Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.
New Mexico Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.
North Carolina Any person with the intent to injure, defraud, or deceive an insurer or insurance claimant is guilty of a crime (Class H felony) which may subject the person to criminal and civil penalties. Oklahoma WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any
insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
Pennsylvania Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false
information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
Tennessee, Virginia It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
TO BE COMPLETED BY THE EMPLOYEE
Employee Last Name Employee First Name MI
Date of Birth Social Security Number Sex
Street Address Apartment No.
City State Zip Code
TO BE COMPLETED BY THE EMPLOYER
New Enrollment Add
Dependent(s)
Change
Address Phone
Name COBRA
Cancel Coverage
Policy Holder
Dependent(s)
Reason for Change Employment Status
Qualifying Event:
(PLEASE STATE)___________________________________________
Requested Effective Date Date of Employment
AVESIS ADVANTAGE VISION CARE EMPLOYEE ENROLLMENT FORM
Underwritten by Fidelity Security Life Insurance Company Kansas City, Missouri
Policy No. VC-16/VC-23MACY C. O’BRIEN SCHOOL DISTRICT #90 & PINAL COUNTY SPECIAL EDUCATION 12345-1234
01 900
I authorize deductions from my earnings at the required contributions towards the cost of the coverage.
Signature Date
A-00713 M-9059/M-9069/M-9086
Dependent Name Date of Birth
Spouse /
Domestic Partner
Child
Child
Child
Child
Child
Child
Male Female
Do you wish to cover your eligible dependents? Yes No
If yes, complete the following:I would like to cover additional eligible dependents
(PLEASE LIST ON A SECOND ENROLLMENT FORM)-
/ -
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PLEASE PRINT LEGIBLY
/
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01/12 - R03
/
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FIRST LAST
Vision Examination
FRAMES
SPECTACLE LENSES
Contact Lenses
LASIK Surgery
Additional Discounts
Group Details
Benefit Frequency
Co-Pays
Rates
Out-of-Network
Reimbursement
www.avesis.com
Progressive Lenses
Are discounted up to 20% off retail in addition to a $50 allowance
Lens Options, Non-Covered Items and Additional Purchases
Are discounted up to 20% off retail
Specialty Lenses
Are discounted up to 20% off retail in addition to the corresponding standard lens allowance LASIK Surgery
5% - 25% off retail
In-Network Benefits
Ask your vision care provider about the premium No-Glare lens
AND
*
**
Vision Exam
Spectacle Lenses
Frames
Contact Lenses
Effective Date:
Group Number:
Plan #:
Vision Examination
Materials
Exam
Standard Single Vision Standard Bifocal Standard Trifocal Standard Lenticular Progressive Specialty Lenses Frame
Contact Lenses (Elective) Contact Lenses (Med. Necessary) LASIK Surgery
Corresponding Standard Lens Reimbursement Up to:
Every:
Your vision exam is covered in full after a co-pay.
Medically necessary contact lenses are covered in full (prior authorization is required)
Your vision health is an important part of complete wellness. Avesis is pleased to
present your vision benefits which are designed to give you and your covered family
members the care, value and service to help maintain good vision and overall health.
Sample Group
12 Months 12 Months 12 Months 24 Months
$10.00
$10.00
In lieu of frames and spectacle lenses, members receive an allowance up to $130 for materials and fit and follow-up exam
$25.00
$40.00
$50.00
$80.00
$40.00
$35.00
$130.00
$250.00
$150.00
$45.00
NANA NA Employee Paid Rates Per Month Providers typically charge between
$100 - $150* for frames covered in full by your plan allowance.
Standard lenses are covered in full. Providers typically charge between
$60 - $120* for standard lenses.
Employee Only Employee + One Employee + Family
$200*
average
retail
Members receive a one-time/lifetime allowance of $150
Values provided may be more or less depending on the providers retail pricing.
Provider wholesale frame pricing for your plan is $50. Participating Wal-Mart locations cover frames up to a
$68 retail value.
Underwritten by: Fidelity Security Life Insurance Company, Kansas City, MO Policy #: VC-16, Form M-9059
