FAIRFAX COUNTY PUBLIC SCHOOLS

CAREFIRST BLUECHOICE ADVANTAGE PLAN

Vision Benefits Davis Vision

Davis Vision

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Q. Who provides vision coverage when enrolling in the CareFirst plan?

A. Comprehensive vision coverage is provided by Davis Vision, a leading national vision company, through CareFirst. Both in and out-of-network benefits are included.

Q. How large is the Davis Vision network?

A. Davis Vision has 50,000 points of access across the country that include private practitioners, retail locations and dispensing labs:

For Eyes Sears Optical Sams Club Pearle Vision J.C. Penney Optical Wal-Mart Vision Centers Visionworks Target Optical Americas Best and many others

Q. How do I determine if my provider is in the Davis Vision network?

A. Go to www.carefirst.com/fcps and click on Find a Doctor or Provider in the Davis Vision Plan in the Member Tools section, or contact Davis Vision at 1-888-343-3462.

2017

http://www.carefirst.com/fcpshttp://www.carefirst.com/findadocvision

Davis Vision

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Q. What are my benefits/copayments under the Davis Vision plan?

A. Benefits include:

Eye exams: $20 copay for a comprehensive eye exam at a participating Davis Vision provider (once per calendar year) Eyeglass frames: Covered once every 2 calendar years

No copay for Fashion or Designer frames from the Davis Vision Frame Collection; $25 copay for Premier frames from the Davis Vision Frame Collection $130 allowance for frames not included in the Davis Vision Frame Collection

You can view the Davis Vision Frame Collection by going to www.carefirst.com/fcps Click on Find a Doctor or Provider in the Davis Vision Plan in the bar labeled Member Tools

Lenses (either eyeglass or contacts): Covered once each calendar year Spectacle lenses: No copay for clear plastic single-vision, lined bifocal, trifocal or lenticular lenses. Contact Lenses: No copay for up to 4 boxes of disposable contact lenses (or 2 boxes of planned replacement contact lenses) if included in the Davis Vision Contact Lens Collection. The Collection Includes CooperVision and Vistakon, in both traditional and silicone hydrogel materials, as well as select torics and multifocal lenses. Your participating eye care provider will have a copy of the latest Davis Vision Contact Lens Collection.

2017

http://www.carefirst.com/fcpshttp://www.carefirst.com/findadocvision

Q. My eye care provider is not in the network. Do I receive benefits?

A. Yes, out-of-network benefits are available, but greater savings are achieved by seeing in-network providers. If an out-of-network provider is selected, you will pay the full cost to the provider and then submit a claim for reimbursement. Go to www.carefirst.com/fcps and click on Davis Vision Benefit Summary for in and out-of-network benefit levels. The out-of-network claim form can also be found on www.carefirst.com/fcps.

Q. Can I request my provider be added to the network?

A. Yes. Contact a member service representative at 1-888-343-3462.

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Davis Vision 2017

http://www.carefirst.com/fcpshttp://www.carefirst.com/fcps

Davis Vision

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Q. I need progressive lenses. Are these covered?

A. Many lens options are available for discounted fees. Go to www.carefirst.com/fcps and click on Davis Vision Benefit Summary for more details.

Q. Is laser vision correction surgery covered?

A. While laser vision correction surgery is not a covered benefit, members are entitled to savings of up to 25% off the providers usual and customary fees, or a 5% discount on any advertised special through our network of physicians and refractive surgery centers (some centers provide a flat fee equating to these discount levels). Refer to the website, www.carefirst.com/fcps for more details.

Q. How frequently can I get an eye exam?

A. You may receive a routine eye exam once per calendar year.

2017

http://www.carefirst.com/fcpshttp://www.carefirst.com/fcps

Davis Vision

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Q. Who do I contact to get more information?

A. Contact Davis Vision at 1-888-343-3462

Monday - Friday: 8 a.m. to 11 p.m. (Eastern Time) Saturday: 9 a.m. to 4 p.m. Sunday: 12 p.m. to 4 p.m. or visit: www.carefirst.com/fcps

Click on Find a Doctor or Provider in the Davis Vision Plan in the Member Tools section, and

Click here for the Davis Vision Benefit Summary

2017

http://www.carefirst.com/fcpshttp://www.carefirst.com/findadocvisionhttp://www.carefirst.com/findadocvisionhttp://www.carefirst.com/findadocvisionwww.carefirst.com/fcps/attachments/davis-vision-benefit-summary-2017.pdf

WWW.CAREFIRST.COM/FCPS

Thank You

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CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., CareFirst BlueChoice, Inc., First Care, Inc. and The Dental Network are independent licensees of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association.

Registered trademark of CareFirst of Maryland, Inc.

Notice of Nondiscrimination and Availability of Language Assistance Services

CareFirst BlueCross BlueShield, CareFirst BlueChoice, Inc. and all of their corporate affiliates (CareFirst) comply with applicable federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability or sex. CareFirst does not exclude people or treat them differently because of race, color, national origin, age, disability or sex. CareFirst:

Provides free aid and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats)

Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages

If you need these services, please call 855-258-6518. If you believe CareFirst has failed to provide these services, or discriminated in another way, on the basis of race, color, national origin, age, disability or sex, you can file a grievance with our CareFirst Civil Rights Coordinator. Civil Rights Coordinator, Corporate Office of Civil Rights Telephone Number 410-528-7820

Mailing Address P.O. Box 8894 Baltimore, Maryland 21224

Fax Number 410-505-2011

Email Address civilrightscoordinator@carefirst.com You can file a grievance by mail, fax or email. If you need help filing a grievance, our CareFirst Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

mailto:civilrightscoordinator@carefirst.comhttps://ocrportal.hhs.gov/ocr/portal/lobby.jsfhttp://www.hhs.gov/ocr/office/file/index.html

CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., CareFirst BlueChoice, Inc., First Care, Inc. and The Dental Network are independent licensees of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association.

Registered trademark of CareFirst of Maryland, Inc.

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(Amharic) -

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tt a fi s fn lti t 0. Ngbt aoj kan b dhn, s d t o f a s so p m gbuf kan.

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CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., CareFirst BlueChoice, Inc., First Care, Inc. and The Dental Network are independent licensees of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association.

Registered trademark of CareFirst of Maryland, Inc.

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CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., CareFirst BlueChoice, Inc., First Care, Inc. and The Dental Network are independent licensees of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association.

Registered trademark of CareFirst of Maryland, Inc.

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