Co-payment for each member at the time of service

Exa m

Lenses and/or frames

$10 $15

VisionCare Plan Overview

ID Card

VisionCare Plan offers you and your family an outstanding

benefit plan that covers all routine eye care, including eye

exams and eyeglasses (lenses and frames) or contacts. The

plan features:

In-network and out-of-network benefits

Enhanced in-network benefits

National panel of optometrists and

ophthalmologists

Frequently Asked Questions

How does the plan work?

The plan is easy to use!

1. Your ID card and a certificate of coverage will be mailed to your

home. The certificate gives detailed information about VisionCare

Plan benefits.

Plan

Frequencies Exam every 12 months

Lenses every 12 months

Frames every 24 months

2. Present your ID card at the time of your visit. You'll pay any co­

payments at that time.

You have nothing more to do! The doctor provides you with services and

bills CompBenefits directly for the balance of your bill.

Maximum Allowances Network Provider

(after co-payments;

up to plan limits)

Non-network

Since the plan is designed to meet your eye care needs,optional upgrades

(like frames costing more than the plan limits, progressive

Eye Exam Lenses

(per pair)

Paid in full $35

lenses, or contacts that are not medically necessary) will cost extra.

However, since all upgrades are on a wholesale basis, your cost will be

lower than what you would pay on your own.

What are the advantages of using a network provider?

CompBenefits' national network of providers provides you with one­ stop

shopping. You'll receive eye exams and materials and pay nothing more

than your co-payment (cosmetic options will include additional charges).

What if I want to see a provider not in your network ?

Single

Bifocal

Trifocal

Lenticular

Contact Lenses Elective

(exam & lenses)

Medically necessary*

Frame

Lasik

Paid in full

Paid in full

Paid in full

Paid in full

$150**

Paid in full

$45 wholesale

$25

$40

$60

$100

$150**

$210

$45 retail

If you prefer, you can visit a non-network doctor. You will pay the

doctor's regular charges, and CompBenefits will reimburse you according

to the plan's non-network benefit schedule.

How can Iget more information?

You may contact CompBenefits' Member Services Department with any

questions or concerns at 1-800-865-3676 , M-F 8am-6pm EST. You may

also locate us on the web at www.mycompbenefits.com.

Members receive benefits when services are received from a TLC Truvision

network provider with the following preferred rates:

• Silver Package: $895/eye for Conventional LASI K

• Gold Package: $1,295/eye for CustomLASIK

• Platinum Package: $1,895/eye for CustomLASIK plus Bladeless LASIK (using

lntraLase technology).

Members will also receive a 10% discount off UCR charges at other preferred LASIK

provider locations, and pay no more than $1,800 per eye for the Conventional LASIK

procedure and $2,300 per eye for CustomLASIK.

• Medically necessary (prior authorization required) is defined as 1) follow

ing cataract surgery w/o intraocular lens; 2) correction of extreme visua

lacuity problems not correctable with glasses; 3) anisometropia greater

than 5.00 diopters and asthenopia or diplopia, with spectacles;4)

Keratoconus; or 5) monocular aphakia and/or binocular aphakia where the

doctor certifies contact lenses are medically necessary for safety and

rehabilitation to a productive life.

**This allowance is paid with the same frequency as lenses, in place of all other

benefits.

This schedule shows only a few of the covered procedures . Please see your Benefit

Administra tor for a complete schedule. This schedule is intended for comparison purposes

only. The benefits of each plan will be determined by the contract. For a complete listing

of benefits, exclusions , and limitations, please reference your certificate of coverage.

Monthly rates for: State of Arkansas

Effective Date:

Employee Only $8.24Employee + Family $21.42

Semi-Monthly

Employee Only $4.12Employee + Family $10.71

TLC

888-358-3937

(designated locations only)

$895 $1,295 $1,895*

LasikPlus

866-757-8082 $6953* $1,395*

LasikPlus free LasikPlus free enhancements for 1 year enhancements for life

$1,895*

LasikPlus free enhancements for life

QualSight LASIK

855-456-2020 $895 $1,295

QualSight free with QualSight Lifetime enhancements for 1 year Assurance Plan

$1,995*

$1,320 with QualSight Lifetime Assurance Plan

HumanaVision Reduced fees

Lasik procedures are available if you are nearsighted or have astigmatism and wear glasses or contacts.2 We have

contracted with many well-known facilities and eye doctors to offer these procedures at substantially reduced fees.

You can take advantage of these low fees when procedures are done by network providers. The network locations listed

below offer the following prices (per eye):

Conventional / Traditional Custom

Opening doors to better vision

for thousands of people – with

affordable Lasik procedures1

Network doctors can help you

understand these new procedures

and provide access to our network

of Lasik providers.

1 Laser-assisted in-situ keratomileusis

2 If qualified as a Lasik candidate by the network doctor

3 Nearsighted better than -2 with astigmatism better than -1 and other restrictions apply

The Lasik program is a discount only for HumanaVision members and is not a covered benefit.

Insured by Humana Insurance Company or CompBenefits Insurance Company, or The Dental Concern, Inc.

GN-52223-HV 2/11

GCA0AV3HH 4/11

*with IntraLaseTM

You can also use independent Lasik provider network doctors to receive a 10% discount

from usual and customary prices and pay no more than $1,800 per eye for Conventional Lasik and $2,300 per eye for Custom Lasik.

Easy access to service

During your comprehensive eye health examination, your doctor can determine if you are a candidate for Lasik. If you qualify, the doctor can also

make arrangements for the procedure with one of the centers that participates in this program.

Your HumanaVision ID card verifies your eligibility for Lasik discounts. You can obtain a list of providers from our website,

HumanaVisionCare.com or by calling a Customer Care Specialist at 866-537-0229.

This discount cannot be combined with any other discount or promotional offer. The HumanaVision Lasik program is not

affiliated with any medical or health plan.

Insured by Humana Insurance Company, CompBenefits Insurance Company, CompBenefits of

HumanaDental Insurance Company, CompBenefits Company, or The Dental Concern, Inc.

List all members to be enrolled or affected by change

Coverage Changes

$8.24

$21.42

1738312

Arkansas State Employees Benefit Advisors1512 Macon Drive, Suite 1ALittle Rock, Arkansas 72211

(501) 224-5234, Toll Free (888) 224-5233

VisionCare Enrollment/Change Form

State of Arkansas

FAX COMPLETED FORM TO ARSEBA: (501) 6 3-

Vision 0314