Summary of Fashion Advantage Gold Option I Benefits
BENEFIT	NETWORK	OUT-OF-NETWORK
REIMBURSEMENT(1)	
FREQUENCY(2)		
Eye examination (including dilation, as professionally indicated)	Once every 12 months under age 19/24 months of age 19 or older	
Eyeglass lenses	Once every 12 months under age 19/24 months of age 19 or older	
Frames	Once every 24 months	
Contact lenses (in lieu of eyeglass lenses)	Once every 12 months under age 19/24 months of age 19 or older 	
EYE EXAMINATION (including dilation as professionally indicated)	Covered In Full 	Plan pays up to $40	
FRAMES			
Fashion level frames from “The Collection”	Covered In Full		
Designer level frames from “The Collection”	Member pays $20 		
Premier level frames from “The Collection”	Member pays $40		
Retail allowance towards a provider’s frame	Plan pays up to $100	Plan pays up to $64	
STANDARD EYEGLASS LENSES(3) (per pair)			
Single vision	Covered In Full	Plan pays up to $30 	
Bifocal	Covered In Full	Plan pays up to $40	
Trifocal	Covered In Full	Plan pays up to $60	
Lenticular	Covered In Full	Plan pays up to $80 	
OPTIONAL EYEGLASS LENSES (per pair)			
Standard progressive lenses(4) (in lieu of bifocal or trifocal lenses)	Covered in Full	Plan pays up to $130	
Premium progressive lenses(4)	Member pays $40	Not Covered	
Glass Grey #3 prescription sunglasses	Member pays $11	Not Covered	
Polycarbonate lenses			
	Adult(5)	Member pays $30 	Not Covered	
	Dependent children			
		Single vision Polycarbonate lenses (in lieu of single vision eyeglass lenses)	Covered In Full	Plan pays up to $70	
		Bifocal Polycarbonate lenses (in lieu of bifocal eyeglass lenses)	Covered In Full	Plan pays up to $80	
		Trifocal Polycarbonate lenses (in lieu of trifocal eyeglass lenses)	Covered In Full	Plan pays up to $95	
Blended segment lenses	Member pays $20 	Not Covered	
Intermediate vision lenses	Member pays $30 	Not Covered	
Glass photochromic lenses	Member pays $20	Not Covered	
Plastic photosensitive lenses	Member pays $65 	Not covered	
High-index (thinner and lighter) lenses	Member pays $55 	Not Covered	
Polarized lenses	Member pays $75	Not Covered	
OPTIONAL EYEGLASS LENS COATINGS/TREATMENTS			
Fashion, sun or gradient tinted plastic lenses	Member pays $11 	Not Covered	
Ultraviolet Coating	Member pays $12	Not Covered	
Scratch-resistant coating
Scratch Protection Plan Single Vision
Scratch Protection Plan Multifocal	Covered In Full
Member pays $20
Member pays $40	Not Covered
Not Covered
Not Covered	
Standard ARC (anti-reflective coating)	Member pays $35	Not Covered	
Premium ARC (anti-reflective coating)	Member pays $48	Not Covered	
Ultra ARC (anti-reflective coating)	Member pays $60 	Not Covered	
CONTACT LENSES(6) (in lieu of eyeglass lenses—per pair or initial supply of disposable contact lenses)			
Contact lens evaluation and fitting			
	Daily wear/ Extended wear	Covered in full when the performing provider dispenses formulary contact lenses	Not Covered	
		
Formulary(7)/Nonformulary		
Standard daily wear contact lenses	Covered In Full/Plan pays up to $130(8)	Plan pays up to $115	
Specialty contact lenses	Covered In Full/Plan pays up to $130(8)	Plan pays up to $115	
Disposable contact lenses	Covered In Full/Plan pays up to $130(8)	Plan pays up to $115	
Medically necessary contact lenses (prior approval required)	Covered In Full	Plan pays up to $225	
LOW VISION SERVICES		
Evaluation – one visit every 5 years (prior approval required)	Plan pays up to $300 per visit	
Follow-up visits—up to four follow-up visits every 5 years	Plan pays up to $100 per visit	
Low vision aids	Plan pays up to $600 per aid/$1,200 lifetime maximum	
(1)	If you choose an out-of-network provider, you must pay the provider directly for all charges and then submit a claim for reimbursement.
(2)	Eligibility will be determined from the date of the last similar service paid under this program, or any other Highmark vision program for this group.
(3)	Includes glass, plastic or oversized lenses.
(4)	Progressive multifocals can be worn by most people. Conventional bifocals will be supplied at no additional charge for anyone who is unable to adapt to progressive lenses. However, the discounted price will not be refunded.
(5)	Discounted member price waived for monocular patients and patients with prescriptions +/- 6.00 diopters or greater.
(6)	Contact lenses can be worn by most people. Once the contact lens option is selected and the lenses fitted, they may not be exchanged for eyeglasses.
(7)	Disposable contact lens wearers will receive four multi-packs of lenses. Planned replacement contact lens wearers will receive two multi-packs of lenses.
(8)	Reimbursement amount is applied towards cost of contact lenses. The allowance may or may not apply to the evaluation/fitting.

Network providers—The Davis Vision provider network is being used through a contractual arrangement between Davis Vision and Highmark. Davis Vision is an independent company that manages a network of licensed vision providers in both private practice and retail locations. Network providers are reviewed and credentialed to ensure that standards for quality and service are maintained.

Network retail locations—In order to provide you with the greatest amount of flexibility and convenience, the network includes a number of retail establishments. Benefits at the retail locations may vary slightly from other locations, as noted in this benefit description. However, your value is comparable.

Locating a network provider—To find a network provider, go to www.highmarkbcbs.com and click on “find an eye care provider.” Enter your zip code and mile radius then click on “Search” to see the most current listing of providers that will accept your vision plan.

Receiving services from a network provider:
•	Call the network provider of your choice and schedule an appointment.
•	Identify yourself as a Highmark member, or eligible dependent, in a vision plan administered by Davis Vision.
•	Provide the office with your identification (ID) number (located on your Highmark ID card), and the name and birth date of the covered dependent receiving services.
It’s that easy! The provider’s office will verify your eligibility for services. No claim forms are required!

Frame benefit—You may choose from 'The Collection' in most independent network provider offices or a program allowance will be applied toward a network provider's own frames.  Many Collection frames are covered in full or have a nominal copayment which helps you select high-quality frames, while minimizing out-of-pocket expenses. Network retail providers typically do not display the Collection. You will instead be given a program allowance toward your frame purchase. If the chosen frame exceeds the allowance, you will be responsible for any remaining balance.

Contact lenses benefit—Contact lenses may be selected in lieu of eyeglasses. No copayment applies towards the initial supply of formulary contact lenses (many of the most popular standard, soft daily wear; disposable or planned replacement) including fitting/follow-up charges.  A program allowance will be applied toward contact lenses from the provider's own supply (which may or may not include fitting/follow-up charges).  Program allowances will be applied for both contact lenses and contact lens fitting/follow-up charges.  At a network retail location, you will receive an allowance toward the cost of lenses from the retailer’s supply. With prior approval, medically necessary contact lenses will be covered in full at all network provider locations.

Low vision services—You and your covered dependents are entitled to a comprehensive low vision evaluation once every five years and low vision aids up to the plan maximum. Up to four follow-up visits will be covered during the five-year period.

Exclusions—This vision program excludes coverage for certain items and services, including: medical treatment of eye disease or injury; vision therapy; special lens designs or coatings other than those previously described; replacement of lost or stolen eyewear; non-prescription (plano) lenses; and services not performed by licensed personnel.

VALUE-ADDED FEATURES
Replacement contact lens program—Highmark offers a contact lens replacement program to members. This mail order program, Lens 1-2-3®, exclusively allows you to enjoy the guaranteed lowest prices on contact lens replacement materials. Call 1-800-LENS-123 or visit www.LENS123.com with a current prescription. Every order comes with a complimentary starter kit.

Information about laser vision correction services—You and your covered dependents can receive substantial discounts on laser correction procedures. You are entitled to savings of up to 25% off the provider’s usual and customary fees, or a 5% discount on any advertised special through a network of credentialed physicians affiliated with Eye Centers of Excellence. (Some centers provide a flat fee equating to these discount levels.)

Call Member Service Monday through Friday, 8:00 am to 5:00 pm, Eastern Standard Time (EST) at
1-800-223-4795 (TTY users call 1-800-523-2847) to find a network provider, ask benefit questions, verify eligibility or request an out-of-network provider reimbursement form.

For information prior to enrolling, call 1-800-223-4795.