Avesis Benefit Summary 2024

UnityPoint Health Group #60790-1056 UnityPoint - Meriter Group #60790-1751 Plan #065175CZL6 Effective Date: 1/1/2024 Out-of-Network Reliable & Dependable Vision Care Services In-Network Member Cost Reimbursement Avēsis provides exceptional Vision Examination vision care benefits for Includes refraction Coveredinfullafter $10 copay Up to $35 millions of commercial members throughout Retinal Imaging Up to $45 member out-of-pocket (OOP) maximum N/A the country. Materials $10copay The Avēsis vision care (Materials copay applies to frame or spectacle lenses, if applicable.) products give our members Frame Allowance an easy-to-use vision benefit Up to 20% discount above Members receive a $65 wholesale allowance Up to $55 that provides excellent frame allowance.* up to $175 retail value† value and protection. Standard Spectacle Lenses Single Vision Coveredinfullafter $10 copay Up to $25 Rates Bifocal Coveredinfullafter $10 copay Up to $40 EmployeePaid-Monthly Trifocal Coveredinfullafter $10 copay Up to $50 EmployeeOnly $7.13 Lenticular Coveredinfullafter $10 copay Up to $80 Employee+Spouse $13.70 Employee+Child(ren) $15.51 Preferred Pricing Options Level 6 Option Package Employee+Family $20.32 (Single Vision/Multi-Focal) $40/$44(Coveredinfulluptoage19) N/A(Upto$10for Polycarbonate agesupto19) Standard Scratch-Resistant Coating $17 N/A How can we help you? Ultraviolet Screening $15 N/A Avēsis Website: Solid or Gradient Tint $17 N/A www.avesis.com Standard Anti-Reflective Coating $45 N/A Customer Service: Level 1 Progressives Coveredinfull Upto$40 855-214-6777 Level 2 Progressives Coveredinfull Upto$48 7 a.m. - 8 p.m. EST All Other Progressives $140allowance+upto20%discount Upto$48 LASIK Provider: (Single Vision/Multi-Focal) $70/$80 N/A Transitions® 877-712-2010 Polarized $75 N/A PGX/PBX $40 N/A Other Lens Options Up to 20% discount* N/A †  Value may be less depending on the providers retail pricing. Contact Lenses (in lieu of frame and spectacle lenses) *  Discounts are not insured Elective $175allowance Up to $160 benefits. Medically Necessary‡ Covered in full Up to $250 ‡  Enhanced benefit for certain conditons. ¥ Refractive Laser Surgery   Save up to 25% on average Onetime/lifetime $150 allowance Onetime/lifetime LASIK prices when you use Up to 25% provider discount ¥ Qualsight (visit qualsight.com/- Provider discount up to 25%* $150allowance avesis for more information). Frequency + At participating Walmart/ Sam's locations, retail pricing for your plan is . Eye Examination Once every 12months $68 Lenses or contact lenses Once every 12months At participating Costco locations, retail pricing Frame Once every 24months $69.99 is . Avǖsis vision insurance products are underwritten by Fidelity Security Life Insurance Company® (FSL), Kansas City, MO, when insured by FSL. Approved by FSL date of 11/23. Administered by Avǖsis. Policy # VC-16, Form M-9059. AVE-440 ©2023 Avēsis, LLC. All Rights Reserved. rev10202023