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Foundation Vision

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What benefits are provided to Covered Persons?

The covered service must be for vision care services or materials received by a Covered Person while his or her coverage under the policy is in force.

Additionally, the benefit payable is subject to the following:

  • Each covered service may be subject to specific frequency limitations, as shown on the Schedule of Covered Services.
  • Other limitations and exclusions that may affect coverage are shown in the “Exclusions” section of your Certificate.

A Covered Person may choose a provider of his or her choice, and may choose the services of a provider who is a VSP provider or an Out-of-Network provider.

  • If you elect to receive vision care services from a participating provider, plan benefits are provided subject only to your payment of any applicable Copay and applicable benefit amount limitations.
  • If you elect to receive vision care services from an Out-ofNetwork provider and that provider is:

    • a participating retail chain, your benefits are provided subject to your payment of any applicable copay and the participating retail chain program in place with that retail chain.
    • not a participating retail chain, you should pay the provider their full fee. We will reimburse the covered person in accordance with the reimbursement schedule shown on the Schedule of Benefits, less any applicable copayment. Availability of services under the out-ofnetwork provider reimbursement schedule is subject to the same time limits and Copay as those described for VSP provider services.

Services obtained from either type of provider count toward the benefit frequencies shown in the Schedule of Covered Services

How does the copayment affect a Covered Person’s benefits?

The benefits described herein are available to you subject only to your payment of any applicable Copay as described in your Certificate and on the Schedule of Benefits. Any additional care, service and/or materials not covered by this plan may be arranged between you and the provider


Exclusions

No Benefits are payable under the Policy for professional services or materials listed below.

  • Orthoptics or vision training and any associated supplemental testing.
  • Any procedure We determine is not necessary, does not offer a favorable prognosis, does not have uniform professional endorsement or is experimental in nature
  • Crowns, inlays, onlays, cast restorations, or other laboratory prepared restorations on teeth, which may be satisfactorily restored with an amalgam or composite resin filling
  • Any treatment which is elective or primarily cosmetic in nature and not generally recognized as a generally accepted dental practice by the American Dental Association, as well as any replacement of prior cosmetic restorations unless such procedure is listed in the Schedule of Covered Procedures
  • Replacement of bridges unless the bridge is older than the age allowed in the Schedule of Covered Procedures and cannot be made serviceable and replacement of full or partial dentures unless the prosthetic appliance is older than the age allowed in the Schedule of Covered Procedures and cannot be made serviceable
  • Replacement of crowns, inlays or onlays unless the prior restoration is older than the age allowed in the Schedule of Covered Procedures and cannot be made serviceable
  • Orthodontics
  • Prescription drugs, premedication, pharmaceuticals, or analgesia
  • Any charge for a Service for which benefits are available under Worker’s Compensation or an Occupational Disease Act or Law, even if You did not purchase the coverage that is available to You
  • Any charge for a Service performed outside of the United States other than for Emergency Treatment. Benefits for Emergency Treatment performed outside of the United States are limited to a maximum of 0100 per Plan Year
  • Local anesthetic, including light anesthetic, as a separate fee
  • Dental services performed in a hospital and related hospital fees
  • Services covered under an existing medical plan
  • The portion of an expense which is in excess of the reasonable charge
  • General anesthesia and I.V. sedation, unless deemed medically necessary as determined by a professional consultant
  • Corneal Refractive Therapy (CRT).
  • Orthokeratology (a procedure using contact lenses to change the shape of cornea in order to reduce myopia).
  • Refitting of contact lenses after the initial (90 day) fitting period.
  • Plano lenses (lenses with refractive corrections of less than + .50 diopter).
  • Two pair of glasses in lieu of bifocals.
  • Replacement of lenses and frames furnished under this Plan that are lost or broken, except at the normal intervals when services are otherwise available.
  • Medical or surgical treatment of the eye, eyes or supporting structures.
  • Corrective vision treatment of an experimental nature.
  • Plano contact lenses to change eye color cosmetically.
  • Artistically-painted contact lenses.
  • Contact lens insurance policies or service contracts.
  • Additional office visits associated with contact lens pathology.
  • Contact lens modification, polishing, or cleaning.
  • Costs for services and/or materials above Plan Benefit allowances.
  • Services or materials of a cosmetic nature.
  • Services and/or materials not indicated on the Schedule of Benefits as covered Plan Benefits.
  • Any charge for a Service for which Benefits are available under Worker’s Compensation or an Occupational Disease Act or Law, even if You did not purchase the Coverage that is available to you.
  • Local, state and/or federal taxes, except where we are required by law to pay.