Premium Vision PPO (52)

Premium Vision PPO (52)

Frequency

Employee/

Out-of-

Spouse/Adult

Children

Benefit

In-Network

Network

Dependents through age 18

Copayment (applies to vision exam)

$15

N/A

Examination (less copayment)

100%

$40

12 months

12 months

Lenses (for glasses)

Lens reimbursement percentage is based on the base cost of the lens and does not include overages or lens add-ons. Out of network amount

reflects the total amount reimbursed for services.

Single Vision

100%

$40

12 months

12 months

Bifocal

100%

$50

12 months

12 months

Trifocal

100%

$75

12 months

12 months

Polycarbonate Lens Material

Available in-network at no cost for children under

100%

Not Covered Not Covered

12 months

age 19

UPMC Vision Advantage does cover progressive lenses at 100% of the base cost of the lens when treated by a participating provider. Any additional

charges above the base cost are not covered and are to be billed to the member. Payment may vary based on the type of lens billed to the plan.

Progressive lenses received from a non-participating provider are reimbursed at $75.

Frames

Frame reimbursement is based on retail value. The plan will reimburse the participating provider 70% of the member's maximum for frames. The

remaining 30% is a contractual discount to the plan and cannot be billed to the member. Any remainder above the member's frame allowance is to

be charged to the member, minus a 20% discount and can be collected at the time of service when a participating provider is used.

Frames

$100

$55

12 months

12 months

Contact Lenses (In Lieu of Glasses)

Contact lens fitting and follow-up reimbursement is separate from contact lens material.

For specialty contact lens evaluation, the provider may bill the patient the difference between the provider's billed charges and the plan/member

allowance. Provider cannot balance bill for standard lens evaluation when received in-network.

Contact lens material is reimbursed at 100% of billed charges up to the member's plan maximum when a participating provider is used.

Contact Lens Fitting and Follow Up

$50

$40

12 months

12 months

Contact Lens Material

$100

$80

12 months

12 months

Out of network reimbursement is based on Usual, Customary, and Reasonable as determined by UPMC Vision Advantage.

Members are eligible for a 20% discount on additional examinations, frames and lenses for glasses received from a participating provider prior to the next eligibility period.

20% Discount does not apply to contact lenses.

Lens reimbursement is based on the base cost of the lens and does not include coverage for lens add-ons and or treatments (such as coatings, tinting, polarization, photochromatics). These services are not covered by or to be billed to UPMC Vision Advantage. Participating providers are to discount these services by 20%.

UPMC Vision Advantage participants are eligible for discounts on LASIK Surgery when received by one of the following preferred providers: UPMC Eye Center, TLC Vision, or QualSight.

This rider may expand or restrict the benefits set forth in your UPMC Vision Advantage Certificate of Insurance. See the Certificate of Insurance for the details of the terms of coverage for your health benefit plan. In the event that the terms of your Certificate of Insurance conflict with this rider, the terms of this rider control.

Pediatric Vision Services are covered in compliance with requirements under the Affordable Care Act (ACA) for members of group plans. Find eligibility and benefit details in your Certificate of Insurance and Pediatric Vision EHB Rider at MyHealth OnLine or call Member Services.

2016

2016

Effective Plan Year

UPMC Health Benefits Inc. Certificate of Insurance PPO Vision Plan

Welcome and General Information for Members

This document is your Certificate of Insurance ("Certificate") for your vision plan. Your Certificate establishes the terms of coverage for your vision plan. It sets forth which services are covered and which services are not covered. It explains the procedures that you must follow to ensure that the vision services you receive will be covered under your benefit plan. It also describes how you can add a dependent to your plan, submit a claim, file a Complaint, and other information that you may need to know to access your vision benefits. The Certificate acts as a contract between you and the Plan,* setting forth your obligations as a Member and our obligations as your vision administrator. It is important to use this Certificate along with your Schedule of Benefits. Your Schedule of Benefits is the document that outlines your coverage amounts and Benefit Limits.

This preferred provider organization benefit plan may not cover all of your vision expenses. Read this contract carefully to determine which vision services are covered.

Health Care Concierge team To help you get accurate answers to questions and up-to-date information about your vision program, please visit MyHealth OnLine via , call 1-888-499-6914, or write to UPMC Vision Advantage, U.S. Steel Tower, 600 Grant Street, Pittsburgh, PA 15219. You can:

? Learn about UPMC Vision Advantage. ? Find network vision providers. ? Verify eligibility for yourself and your dependents. ? Request a Non-Participating Vision Provider reimbursement form. ? Speak with our Health Care Concierge team via phone or online chat. ? Ask any questions about your vision care benefits. ? Initiate a Complaint regarding a benefit denial.

Our Health Care Concierge team is available Monday through Friday from 7 a.m. to 7 p.m. and Saturday from 8 a.m. to 3 p.m. at 1-888-499-6914. Members who use a TTY (teletypewriter) may access TTY services by calling 1-800-361-2629.

Helpful Phone Numbers: ? Member Health Care Concierge team ? 1-888-499-6914 ? Teletypewriter (TTY) ? 1-800-361-2629 ? Provider Service ? 1-877-648-9621 ? Fraud and Abuse Special Investigation Unit ? 1-866-FRAUD01 (1-866-372-8301)

*UPMC Vision Advantage is a product of UPMC Health Benefits Inc., and is administered by UPMC Health Plan Inc. Please note that throughout this document, we use the terms "UPMC Health Plan" and "the Plan" to refer to UPMC Health Benefits Inc. as well as to UPMC Health Plan.

2

2016

TABLE OF CONTENTS

Terms and Definitions to Help You Understand Your Coverage ................................................ Page 4 Eligibility and Enrollment ? When Coverage Begins .................................................................. Page 6 How the Vision Plan Works ........................................................................................................ Page 9 Benefits..................................................................................................................................... Page 10 Claims....................................................................................................................................... Page 12 Resolving Disputes with the Plan ............................................................................................. Page 15 Termination ? When Coverage Ends ....................................................................................... Page 17 Schedule of Exclusions ............................................................................................................ Page 18 General Provisions ................................................................................................................... Page 20

3

2016

Terms and Definitions to Help You Understand Your Coverage

The following are some important, frequently used terms and definitions that the Plan uses in this Certificate and when administering your benefits.

Benefit Limit ? The maximum amount that the Plan will pay for a Covered Service. Some Benefit Limits are discussed in this Certificate, but generally Benefit Limits are set forth in your Schedule of Benefits.

Benefit Period ? The period (for which you are eligible for coverage during your employer group/plan sponsor's contract year) during which charges for Covered Services must be incurred in order to be eligible for payment by the Plan. A charge is considered incurred on the date you receive the service or supply.

Complaint ? A dispute or objection by a Member regarding a Participating Vision Provider or the coverage (including contract exclusions and non-covered benefits), operations, or management policies of this vision plan, which has been filed with the Plan but has not been resolved by the Plan. Instructions on how to file a Complaint are set forth in the Resolving Disputes with the Plan section of this Certificate.

Contract Holder ? Person responsible for payment of premiums, or person whose employment is the basis for membership in a health plan.

Copayment ? The specified dollar amount that you pay at the time of service for certain Covered Benefits. You are expected to pay your Copayment at the time of service. Refer to your Schedule of Benefits to determine Copayment amounts.

Covered Benefit or Covered Service ? A service or supply that meets the requirements set forth in this Certificate.

Experimental/Investigational ? Any treatment, procedure, equipment, drug, device, or supply which is not accepted standard vision practice by the general vision community or does not have federal or government agency approval.

Interim Discount Benefit ? Members are eligible for a 20% discount on additional examinations, frames, and lenses for glasses when received from a participating provider prior to the next eligibility period.

Maximum Allowable Fee Schedule Amount ? The maximum amount the Plan will allow for a Covered Service.

Member ? An individual or dependent who is enrolled in and covered by this Certificate.

Non-Participating Vision Provider ? A vision provider who is not a contracted provider with the Plan.

Participating Vision Provider ? A vision provider who has entered into an agreement with the Plan to render Covered Services to UPMC Vision Advantage Members.

Proof of Loss ? Documentation to support a claim.

Rider ? A document that modifies your Certificate. A Rider may expand or restrict the benefits set forth in your Certificate. If you are unsure if you have a Rider, contact UPMC Vision Advantage or

4

2016

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